Bundled Payment Collaborative Overview July 2012

Rockwall Regional Hospital (Texas Health Rockwall) Community Health Needs Assessment 2013 Table of Contents

Executive Summary • Why a Community Health Needs Assessment • Community Health Improvement Vision and Goals • Executive Summary of Health Needs • Addressing the Health Needs of the Community Community Health Needs Assessment • Secondary Data Assessment » Definition of the community » Demographic assessment of the community » Economic indicators » Health status and access indicators » Community supply of health care service providers and resources » Community demand / health services use » Review of other recent community health needs assessments • Primary Data Assessment » Summary of community input » Identification of people representing the community’s interests • Notes to the Study » How the assessment was conducted including data sources » Process for consulting with people representing the community’s interest » Process for identifying and prioritizing health needs and services » Gaps that limited ability to assess the community’s health needs

Texas Health Resources, a leading faith-based nonprofit health care system in North Texas, is committed to improving the health and well-being of the people who live and work in the communities we serve. Texas Health provides hospital care, but also offers programs intended to educate people about health and provide them with resources to prevent illness, maintain health and improve their overall well-being. Texas Health has completed this community health needs assessment in order to better understand the health status and needs of the community and use the knowledge gained to implement programs that will benefit the community by: Identifying unmet needs in community health and developing strategies to address those unmet needs Informing the community about health services and available resources

For more information regarding Texas Health Resources please visit http://www.texashealth.org

Statement: Rockwall Regional Hospital, a Texas Health Resources joint venture partner, is supportive of Texas Health’s efforts to improve the health and well-being of the people who live and work in the communities we serve. Goals: “Community Health supports the mission and core business of Texas Health by targeting preventive health/wellness activities and services to ensure the fulfillment of its charitable mission, to positively impact the health status of disproportionate unmet health needs populations, to facilitate the coordination of care (specifically prevention and disease management outreach activities) across the entire community, and provide community based activities that support and enhance hospital service lines and key performance indicators.” Source: Texas Health Resources 6 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Executive Summary COMMUNITY HIGHLIGHTS LESS FAVORABLE MORE FAVORABLE TEXAS AVERAGES Population Growth Estimates <0% 0-7.3% >7.3% 7.3% Community overview and populationPopulation percentage of Age <18 health indicators<25% 25-27% >27% 27.0% Median Household Income <$49,000 NA >$49,000 $49,000 Population Below 200% Federal Poverty Level >50% 44.9-50% <44.9% 44.9% Percent of Uninsured >25% 24-25% <24% 24.0% Community Highlights Avoidable Inpatient Admissions Health>1526.1 Indicator1272.6-1526.1 Groups<1272.6 1,272.6 Rockwall Regional Hospital’s community is comprisedEmergency of Room Usage >411.3 385.6-411.3 <385.6 385.6 Primary Care Supply Birth Indicators<0 -such asNA >0 Provider supply defined by population need 415,000 people, and is projected to grow to 504,000 percent of low birth weight people by 2017; a growth rate of 21.4% exceeding that of HEALTH INDICATOR GROUPS babies orLESS teen FAVORABLE birth rates MORE FAVORABLE Texas 7.3%. Birth, Death, General Health, Health Screenings, The percentage of total indicators, Clinical Prevention Services, Chronic Diseases and within each health indicator group, The community is young, having 29.0% of the populationConditions, Physical Environment, SubstanceDeath Use and indicators-such as all that are less favorable than the Texas average. younger than age 18, compared with 27.0% in TexasReportable and Conditions cause deaths>35% or deaths20-35% from <20% 23.5% in the U.S. cancer Median household income is $62,925, compared with General Health-such as self $49,000 in Texas and $50,000 in the U.S. reported healthy days or no exercise A figure of 21.9% of the population is reported below Health Screenings-such as 200% Federal Poverty Level, less than the Texas figure of diabetes or cholesterol 44.9% or U.S. figure of 39.0%. screening The community’s percentage of uninsured persons is Clinical Prevention Services- 16.2%, which is lower than the Texas average of 24.0%, such as an annual physical but slightly higher than the 16.0% in the U.S. or vaccination Overall, the population has fewer avoidable inpatient Chronic Diseases and admissions than Texas or the U.S. Conditions-such as diabetes or asthma This population also uses the emergency room at a lower County-level Physical rate than the overall Texas or U.S. populations. Environment-such as crime rate or adult literacy There is an overall shortage of primary care physicians, County-level Substance Use and the shortage is larger when considering physicians and Reportable Conditions- who accept Medicare and Medicaid. such as drinking and chicken pox vaccinations 7 Please see the following page for expanded legend criteria. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Executive Summary Criteria for community highlights and health indicator groups

COMMUNITY HIGHLIGHTS LESS FAVORABLE MORE FAVORABLE TEXAS AVERAGES Population Growth Estimates <0% 0-7.3% >7.3% 7.3% Population percentage of Age <18 <25% 25-27% >27% 27.0% Median Household Income <$49,000 NA >$49,000 $49,000 Population Below 200% Federal Poverty Level >50% 44.9-50% <44.9% 44.9% Percent of Uninsured >25% 24-25% <24% 24.0% Avoidable Inpatient Admissions >1526.1 1272.6-1526.1 <1272.6 1,272.6 Emergency Room Usage >411.3 385.6-411.3 <385.6 385.6 Primary Care Supply <0 NA >0 Provider supply defined by population need

HEALTH INDICATOR GROUPS LESS FAVORABLE MORE FAVORABLE Birth, Death, General Health, Health Screenings, The percentage of total indicators, Clinical Prevention Services, Chronic Diseases and within each health indicator group, Conditions, Physical Environment, Substance Use and that are less favorable than the Texas average. Reportable Conditions >35% 20-35% <20%

Rockwall Regional Hospital’s efforts to address the health needs of the community will focus on Rockwall two areas: Awareness, Literacy and Navigation Regional Community Health Issues Hospital (ALN) and Chronic Disease. The following Access: Provider Supply X strategies will be implemented: Awareness, literacy, navigation Cancer Chronic Disease X Awareness, Literacy and Navigation Injury and Violence X • Development of an Area Resource Maternal, Infant, and Child Health X Guide Mental Health X Nutrition, Physical Activity, and Obesity • Maintain Existing Programs with Oral Health X Awareness, Literacy and/or Navigation Other Clinical/Preventive X Preventive/Wellness focus Reproductive and Sexual Health • Educational Programs Social Determinants X • Sponsorship of Area Collaboratives Substance Abuse X Tobacco Transportation X Chronic Disease • Maintain Existing Programs with Chronic Disease focus • Educational Programs Vast amounts of quantitative and qualitative data were collected, refined and analyzed during this Community • School Partnerships Health Needs Assessment process. Detailed data is • Sponsorship of Area Collaboratives presented in this document. The chart above summarizes the most significant health issues facing the community.

9 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Community Health Needs Assessment Secondary Data Assessment: • Definition of the Community • Demographic Assessment of the Community • Economic Indicators Rockwall Regional Hospital Definition of the community

Community Zip Codes: 75032 Rockwall Rockwall County 75043 Garland Dallas County 75048 Sachse Dallas County 75087 Rockwall Rockwall County 75088 Rowlett Dallas County 75089 Rowlett Dallas County 75098 Wylie Collin County 75126 Forney Kaufman County 75132 Royse City Rockwall County 75135 Caddo Mills Hunt County 75160 Terrell Kaufman County 75164 Nevada Collin County 75166 Lavon Collin County 75173 Nevada Collin County 75182 Sunnyvale Dallas County 75189 Royse City Rockwall County 75401 Greenville Hunt County 75402 Greenville Hunt County 75442 Farmersville Collin County 75474 Quinlan Hunt County

The community is slightly younger than Texas or the U.S. • The community has a lower percentage of persons aged 65 and older, 9.1 percent, than does Texas, 10.8 percent, or the U.S., 14.1 percent. • The community has higher percentage of persons younger than age 18, 29 percent, than does Texas, 27 percent, or the U.S., 23.5 percent. Over the next five years, the overall community is predicted to have strong population growth, 21.4 percent.

2012 Total Population by Age 2012-2017 Absolute Growth by Age 2012-2017 Percent Growth by Age

Zip Code Zip City Name 0-14 15-17 18-44 45-64 65+ Total 0-14 15-17 18-44 45-64 65+ Total 0-14 15-17 18-44 45-64 65+ Total 75032 Rockwall 7,283 1,482 10,685 8,086 2,721 30,257 3,271 378 1,649 2,018 1,312 8,628 44.9% 25.5% 15.4% 25.0% 48.2% 28.5% 75043 Garland 13,748 2,527 23,543 14,011 5,094 58,923 5,435 (228) (276) 607 1,185 6,723 39.5% -9.0% -1.2% 4.3% 23.3% 11.4% 75048 Sachse 5,270 1,020 7,846 4,716 1,354 20,206 2,557 119 568 1,348 546 5,138 48.5% 11.7% 7.2% 28.6% 40.3% 25.4% 75087 Rockwall 7,266 1,514 10,774 7,754 2,909 30,217 3,279 222 1,175 1,747 1,153 7,576 45.1% 14.7% 10.9% 22.5% 39.6% 25.1% 75088 Rowlett 6,373 1,398 8,937 6,391 1,873 24,972 2,008 (130) (283) 380 509 2,484 31.5% -9.3% -3.2% 5.9% 27.2% 9.9% 75089 Rowlett 8,875 1,714 12,160 7,348 1,764 31,861 3,983 118 558 1,878 792 7,329 44.9% 6.9% 4.6% 25.6% 44.9% 23.0% 75098 Wylie 12,765 2,546 20,472 12,734 4,344 52,861 6,345 795 2,908 4,551 1,968 16,567 49.7% 31.2% 14.2% 35.7% 45.3% 31.3% 75126 Forney 9,146 1,953 13,176 9,792 2,850 36,917 4,805 346 2,341 2,719 1,569 11,780 52.5% 17.7% 17.8% 27.8% 55.1% 31.9% 75135 Caddo Mills 1,391 337 2,131 1,667 727 6,253 574 (17) 117 204 193 1,071 41.3% -5.0% 5.5% 12.2% 26.5% 17.1% 75160 Terrell 6,340 1,118 8,992 5,570 2,416 24,436 2,279 156 253 656 568 3,912 35.9% 14.0% 2.8% 11.8% 23.5% 16.0% 75166 Lavon 586 130 1,039 743 303 2,801 272 23 162 206 120 783 46.4% 17.7% 15.6% 27.7% 39.6% 28.0% 75173 Nevada 1,224 260 2,102 1,431 594 5,611 528 56 254 350 205 1,393 43.1% 21.5% 12.1% 24.5% 34.5% 24.8% 75182 Sunnyvale 990 311 2,024 1,550 579 5,454 553 (77) 307 125 202 1,110 55.9% -24.8% 15.2% 8.1% 34.9% 20.4% 75189 Royse City 5,902 1,198 9,216 5,740 2,077 24,133 3,096 208 1,441 1,769 891 7,405 52.5% 17.4% 15.6% 30.8% 42.9% 30.7% 75401 Greenville 4,554 849 7,094 4,337 2,258 19,092 1,428 (17) (72) 368 196 1,903 31.4% -2.0% -1.0% 8.5% 8.7% 10.0% 75402 Greenville 3,102 655 5,029 4,852 2,720 16,358 1,168 13 226 111 544 2,062 37.7% 2.0% 4.5% 2.3% 20.0% 12.6% 75442 Farmersville 2,140 437 3,669 2,277 1,137 9,660 777 58 168 340 235 1,578 36.3% 13.3% 4.6% 14.9% 20.7% 16.3% 75474 Quinlan 3,206 674 4,923 4,372 2,094 15,269 1,081 8 62 (35) 443 1,559 33.7% 1.2% 1.3% -0.8% 21.2% 10.2% Grand Total 100,161 20,123 153,812 103,371 37,814 415,281 43,439 2,031 11,558 19,342 12,631 89,001 43.4% 10.1% 7.5% 18.7% 33.4% 21.4%

Total Community <18 = 29.0% 37.0% 24.9% 9.1% 100.0% <18 = 37.8% 7.5% 18.7% 33.4% 21.4% Texas <18 = 27.0% 38.1% 24.1% 10.8% 100.0% <18 = 4.6% 4.5% 4.8% 19.1% 7.3% U.S. <18 = 23.5% 35.6% 26.8% 14.1% 100.0% <18 = 0.2% 0.0% 0.4% 15.8% 2.2%

Data Sources: U.S. projections from U.S. Census Bureau and Texas projections from the Texas State Data Center. Zip code population estimates and projections were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. 13 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Rockwall Regional Hospital 2012 total population density map

75043, Garland, has the largest zip code population in the community, 59,000. 75166, Lavon, has the smallest zip code population in the community, 3,000.

On average, the community is younger than Texas or the U.S. The percentage of White Non-Hispanic people, 63.5 percent, is similar to the U.S. average, 63 percent, but higher than the Texas average, 42 percent. The percentage of Asian Pacific Islander Non-Hispanic people, 4.5 percent, is higher than the Texas average, 3.1 percent, and the U.S. average, 4.2 percent.

2012 Male Population 2012 Female Population 2012 Population American Asian Pacific Total Total White Non- Black Non- Indian Non- Islander Non- Other Non- Zip Code ZIP City Name 0-14 15-17 18-44 45-64 65+ Male 0-14 15-17 18-44 45-64 65+ Female Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic 75032 Rockwall 12.4% 2.4% 18.2% 13.3% 4.3% 50.7% 11.6% 2.4% 17.2% 13.4% 4.7% 49.3% 70.0% 5.8% 20.9% 0.3% 2.8% 0.2% 75043 Garland 12.0% 2.2% 20.3% 11.3% 3.6% 49.4% 11.3% 2.1% 19.7% 12.5% 5.1% 50.6% 40.6% 22.1% 30.4% 0.4% 6.4% 0.2% 75048 Sachse 13.2% 2.6% 19.5% 11.8% 3.1% 50.3% 12.9% 2.4% 19.3% 11.5% 3.6% 49.7% 61.5% 8.9% 16.8% 0.6% 12.1% 0.2% 75087 Rockwall 12.5% 2.5% 18.3% 12.5% 4.3% 50.1% 11.6% 2.5% 17.4% 13.2% 5.3% 49.9% 78.7% 5.1% 12.6% 0.5% 2.9% 0.1% 75088 Rowlett 12.9% 2.7% 18.2% 12.8% 3.2% 49.9% 12.6% 2.9% 17.6% 12.8% 4.3% 50.1% 65.5% 11.4% 17.5% 0.4% 5.0% 0.1% 75089 Rowlett 14.3% 2.6% 19.2% 11.5% 2.5% 50.2% 13.6% 2.8% 18.9% 11.5% 3.0% 49.8% 55.6% 16.3% 18.7% 0.4% 8.8% 0.2% 75098 Wylie 12.3% 2.4% 19.6% 12.0% 3.8% 50.1% 11.9% 2.4% 19.1% 12.1% 4.5% 49.9% 62.6% 11.9% 17.5% 0.5% 7.4% 0.2% 75126 Forney 12.7% 2.7% 18.1% 13.0% 3.5% 50.0% 12.1% 2.6% 17.6% 13.5% 4.2% 50.0% 68.7% 11.8% 17.5% 0.5% 1.4% 0.1% 75135 Caddo Mills 11.5% 2.8% 17.1% 12.6% 5.3% 49.3% 10.8% 2.6% 17.0% 14.0% 6.3% 50.7% 82.7% 2.5% 13.9% 0.5% 0.4% 0.0% 75160 Terrell 13.5% 2.2% 18.7% 11.1% 4.1% 49.5% 12.5% 2.3% 18.1% 11.7% 5.8% 50.5% 55.2% 19.1% 24.3% 0.4% 1.0% 0.1% 75166 Lavon 10.8% 2.6% 19.6% 13.4% 5.2% 51.6% 10.1% 2.0% 17.5% 13.2% 5.6% 48.4% 80.1% 3.7% 13.9% 1.0% 1.1% 0.2% 75173 Nevada 11.3% 2.6% 19.3% 12.9% 5.0% 51.1% 10.5% 2.1% 18.2% 12.6% 5.6% 48.9% 78.3% 2.9% 17.0% 0.8% 0.9% 0.1% 75182 Sunnyvale 9.2% 2.8% 18.8% 13.7% 4.9% 49.5% 9.0% 2.9% 18.3% 14.7% 5.7% 50.5% 58.5% 10.3% 14.1% 0.4% 16.5% 0.1% 75189 Royse City 12.7% 2.5% 19.8% 12.0% 4.0% 51.0% 11.7% 2.5% 18.4% 11.8% 4.6% 49.0% 73.8% 5.8% 18.4% 0.7% 1.2% 0.1% 75401 Greenville 12.4% 2.2% 19.4% 11.3% 4.8% 50.2% 11.5% 2.3% 17.7% 11.4% 7.0% 49.8% 50.0% 17.7% 30.7% 0.6% 0.9% 0.1% 75402 Greenville 9.8% 2.1% 16.0% 14.5% 7.3% 49.6% 9.1% 1.9% 14.8% 15.2% 9.4% 50.4% 82.7% 6.5% 8.6% 0.6% 1.5% 0.0% 75442 Farmersville 11.4% 2.4% 19.1% 11.7% 5.1% 49.7% 10.8% 2.1% 18.9% 11.8% 6.7% 50.3% 76.1% 3.9% 18.9% 0.6% 0.5% 0.1% 75474 Quinlan 10.8% 2.2% 16.7% 14.1% 6.5% 50.3% 10.2% 2.2% 15.5% 14.6% 7.2% 49.7% 87.1% 1.0% 10.3% 1.0% 0.6% 0.1% % Distribution of Tot Pop 12.4% 2.4% 18.9% 12.3% 4.1% 50.0% 11.7% 2.4% 18.2% 12.6% 5.1% 50.0% 63.5% 11.7% 19.6% 0.5% 4.5% 0.1% Grand Total 51,447 10,138 78,417 50,909 16,839 207,750 48,714 9,985 75,395 52,462 20,975 207,531 259,541 47,966 80,153 2,091 18,181 544

Total Community <18 = 14.8% 18.9% 12.3% 4.1% 50.0% <18 = 14.1% 18.2% 12.6% 5.1% 50.0% 63.5% 11.7% 19.6% 0.5% 4.5% 0.1% Texas <18 = 13.8% 19.2% 11.8% 4.8% 49.6% <18 = 13.2% 18.8% 12.3% 6.1% 50.4% 42.0% 12.0% 40.0% 1.0% 3.1% 2.0% U.S. <18 = 12.0% 18.1% 13.1% 6.1% 49.3% <18 = 11.5% 17.5% 13.7% 8.0% 50.7% 63.0% 12.0% 17.0% 1.0% 4.2% 3.0%

Data Sources: Population estimates and projections were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. U.S. and Texas percentages from Kaiser Family Foundation State Health Facts. 15 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Rockwall Regional Hospital 2012 population by economic indicators The median household income for the community, $62,925, is higher than Texas or the U.S. however there are areas less than the state median. About, 22 percent of the community lives below 200 percent of the Federal Poverty Level (FPL). The percent uninsured in the community, 16 percent is lower than Texas’ average of 24 percent, but there are areas with a higher percent of uninsured. 2012 Population 2012 Population 2010 Inpatient Payermix High School Median Income Income Income Income Population Age 18 + Age 18+ Graduation Household Number Income $15,000- $25,000- $50,000- $75,000- Income below Uninsured Uninsured Managed Zip Code ZIP City Name Percentage Income of HHs < $15,000 $24,999 $49,999 $74,999 $99,999 $100,000+ 200% FPL Count Percent Care Medicare Medicaid Self Pay Other 75032 Rockwall 93.8% $ 81,246 10,132 402 494 2,096 1,707 1,473 3,960 18.0% 3,524 15.3% 1,237 643 272 134 14 75043 Garland 89.9% $ 52,536 21,611 1,662 1,867 6,712 5,285 2,942 3,143 31.6% 8,566 19.7% 2,212 1,720 1,168 494 131 75048 Sachse 94.1% $ 77,212 6,629 348 281 1,189 1,373 1,407 2,031 11.8% 1,313 12.0% 1,000 326 130 107 14 75087 Rockwall 96.0% $ 74,488 10,752 629 685 1,900 2,206 1,931 3,401 10.8% 3,469 13.3% 1,278 1,006 167 136 16 75088 Rowlett 93.3% $ 79,099 8,585 318 285 1,442 1,954 1,783 2,803 18.0% 1,930 10.8% 1,118 725 247 155 38 75089 Rowlett 95.2% $ 77,296 10,080 319 250 1,710 2,550 2,308 2,943 11.9% 2,437 11.7% 1,349 555 307 177 58 75098 Wylie 95.3% $ 69,348 16,981 841 914 3,594 4,014 3,168 4,450 14.9% 4,853 11.2% 2,479 872 513 312 26 75126 Forney 92.1% $ 71,887 11,538 672 645 2,408 2,316 2,313 3,184 10.1% 3,649 13.4% 1,906 654 349 234 13 75135 Caddo Mills 90.7% $ 52,813 2,152 250 177 585 552 317 271 21.8% 1,015 18.3% 214 247 110 64 4 75160 Terrell 87.4% $ 42,036 8,503 1,534 1,069 2,323 1,633 846 1,098 41.5% 4,261 22.6% 1,407 1,435 954 691 8 75166 Lavon 91.9% $ 55,378 960 108 73 235 258 129 157 11.1% 771 16.9% 196 84 21 19 2 75173 Nevada 90.8% $ 55,437 1,896 202 132 502 472 289 299 19.7% ------201 132 69 38 6 75182 Sunnyvale 93.4% $ 72,919 1,877 84 77 432 372 246 666 8.7% 261 10.6% 215 144 18 35 6 75189 Royse City 91.4% $ 60,481 7,889 625 678 1,888 1,706 1,266 1,726 18.5% 2,471 19.6% 1,036 600 346 181 29 75401 Greenville 82.7% $ 33,211 6,908 1,520 1,100 2,199 1,235 434 420 56.3% 4,033 31.4% 525 1,206 667 391 8 75402 Greenville 89.3% $ 51,420 6,591 770 591 1,845 1,438 931 1,016 28.6% 2,296 16.4% 664 1,016 186 215 8 75442 Farmersville 89.7% $ 49,335 3,422 464 322 952 770 459 455 26.8% 1,463 20.8% 418 333 159 84 4 75474 Quinlan 78.4% $ 40,781 5,751 828 828 1,784 1,078 663 570 35.1% 2,100 24.6% 555 953 487 355 23 Grand Total 91.6% $ 62,925 142,257 11,576 10,468 33,796 30,919 22,905 32,593 21.9% 48,412 16.2% 18,010 12,651 6,170 3,822 408 % Distribution 8.1% 7.4% 23.8% 21.7% 16.1% 22.9% 43.9% 30.8% 15.0% 9.3% 1.0%

Total Community 91.6% $ 62,925 21.9% 16.2% Texas 81.0% $ 49,195 44.9% 24.0% U.S. 85.7% $ 50,443 39.0% 16.0%

Data Sources: Federal Poverty Level (FPL) estimates from U.S. Census Bureau. High school graduation, income, uninsured and Texas Health Care Information Council inpatient payer mix, retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. U.S. and Texas percentages from Kaiser Family Foundation State Health Facts and National Information Center for Higher Education Policymaking and Analysis. 16 Gray shading = Community statistic is less favorable than State of Texas. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Rockwall Regional Hospital 2012 percent of 18+ population that is uninsured

Community = 16% Texas = 24% U.S. = 16% 75401, 31%, has the largest percentage of uninsured. 75182, 75088, and 75098, 11%, have the lowest percentage of uninsured.

NOTE: Zip code 75173 does not have a percent uninsured data available

Red shows areas of higher need. This map is based upon a grading system that includes population size and growth, lower income and the number of persons without health insurance.

Data Sources: Population estimates and projections, income and uninsured, Texas Health Care Information Council inpatient payer mix, were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. Higher ranking = higher need based upon the indicator

Prevention Quality Indicators (PQIs) are illnesses that lead to hospital stays that could have been prevented. PQI rates for adult bacterial pneumonia, chronic obstructive pulmonary disease (COPD), adult and pediatric perforated appendix were higher than rates for Texas and/or the U.S.

LEGEND LESS FAVORABLE MORE FAVORABLE Data Sources: Zip code population estimates were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. Zip code level PQI data from Dallas Fort Worth Hospital Council. Notes: Rates are per 100,000 population except for Admissions with perforated appendix, which are per 1,000 admissions with appendicitis. Overall PQI based upon Acute + Chronic. Acute PQI based on the three AHRQ PQIs for bacterial pneumonia, dehydration, and urinary tract infection. Chronic PQI based on the nine AHRQ PQIs for angina, asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and hypertension. Gray shading = community rate is higher than Texas or U.S. rates 20 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Community Defined Health Status Indicators Birth, death and general health status

Data Sources: PULSE™ Healthcare Survey retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. Texas Behavioral Risk Factor Surveillance System (BRFSS) data provided by Texas Department of State Health Services - Center for Health Statistics. Texas Department of State Health Services - Center for Health Statistics and Vital Statistics Units. U.S. Centers for Disease Control and Prevention, Fast Stat reports. 21 Note: Death rates for Texas and community are not age-adjusted but are crude death rates. US. Death rates are age-adjusted. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Community Defined Health Status Indicators Screenings, clinical prevention and chronic diseases

Data Sources: County Health Rankings. Texas Center for the Advancement of Literacy & Learning. Texas Department of State Health Services - Center for Health Statistics and Mental Health and Substance Abuse Division. Texas Health and Human Services Commission. U.S. Bureau of Labor Statistics. U.S. Census Bureau. U.S. Centers for Disease Control and Prevention, Fast Stat reports. U.S. Department of Health and Human Services, Community Health Status Indicators. 23 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Secondary Data Assessment: • Community Supply of Health Care Service Providers and Resources • Community Demand / Health Services Utilization

Health Services in the Community

Many facilities, including the Federally Qualified Health Centers (FQHC) and several charitable clinics are located within Rockwall Regional Hospital’s areas of higher need (shown in red).

Data Sources: Providers from American Academy of Urgent Care Medicine; National Association of Free and Charitable Clinics; Texas Department of State Health Services, Health Facility Program; Texas Department of State Health Services, Texas Primary Care Office; and Urgent Care Association of America. Zip code population estimates and projections were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven.

Rank Major Diagnostic Category (MDC) <18 18-44 45-64 65+ Total The community 1 Pregnancy, Childbirth And Puerperium 2.5% 97.4% 0.1% 0.0% 5,628 2 Circulatory System 1.4% 9.2% 37.3% 52.1% 4,303 uses the hospital 3 Respiratory System 14.5% 8.2% 28.6% 48.7% 3,933 4 Musculoskeletal System And Connective Tissue 4.3% 15.1% 38.1% 42.5% 3,306 at a lower rate 5 Digestive System 9.7% 22.0% 33.2% 35.1% 3,276 6 Nervous System 10.3% 16.4% 31.6% 41.7% 2,111 than the Texas 7 Mental Diseases and Disorders 27.8% 39.9% 23.7% 8.6% 1,936 average. 8 Newborn And Other Neonates (Perinatal Period) 99.9% 0.1% 0.0% 0.0% 1,626 9 Kidney And Urinary Tract 4.9% 18.9% 28.0% 48.2% 1,622 10 Endocrine, Nutritional And Metabolic System 11.7% 28.9% 33.1% 26.4% 1,369 This may be 11 Skin, Subcutaneous Tissue And Breast 14.3% 28.9% 32.8% 23.9% 1,320 12 Factors Influencing Health Status 2.7% 9.1% 30.3% 57.9% 1,179 because the 13 Hepatobiliary System And Pancreas 2.9% 29.4% 42.2% 25.5% 1,115 14 Infectious and Parasitic DDs 8.2% 13.5% 35.5% 42.8% 1,080 people within the 15 Female Reproductive System 1.5% 49.4% 38.1% 11.0% 913 16 Ear, Nose, Mouth And Throat 40.5% 26.9% 16.4% 16.1% 602 community are 17 Blood and Blood Forming Organs and Immunological Disorders 15.3% 20.3% 23.8% 40.6% 522 younger than the 18 Injuries, Poison And Toxic Effect of Drugs 10.6% 34.6% 37.8% 17.0% 518 19 Myeloproliferative DDs (Poorly Differentiated Neoplasms) 19.5% 15.4% 36.1% 29.0% 338 Texas average 20 Male Reproductive System 6.0% 10.8% 48.2% 34.9% 166 21 Multiple Significant Trauma 10.8% 40.5% 23.0% 25.7% 74 and because 22 Eye 32.9% 30.1% 15.1% 21.9% 73 23 Burns 28.0% 32.0% 24.0% 16.0% 25 younger people 24 Ungroupable 19.0% 23.8% 38.1% 19.0% 21 Grand Total 12.7% 30.3% 26.4% 30.6% 37,056 use the hospital Community Discharge Rate per 1,000 population 89.2 1 Texas Hospital Admissions per 1,000 population 102.2 less . U.S. Hospital Admissions per 1,000 population 113.6

Data Sources: Texas Health Care Information Council Inpatient Public Use Data File Jan-Dec 2010, were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. U.S. and Texas percentages from Kaiser Family Foundation State Health Facts. 1Number, rate, and average length of stay for discharges from short-stay hospitals, by age, region, and sex: United States, 2010. National Hospital Discharge Survey. Center for Disease Control and Prevention. Available http://www.cdc.gov/nchs/data/nhds/1general/2010gen1_agesexalos.pdf Last accessed March 22, 2013. Note: Acute care hospital discharges only excludes normal newborns. - Facilities not reporting due to small volume: Texas Health Specialty Hospital, Texas Institute for Surgery - Facilities opened during 2010: Flower Mound Hospital Partners, Baylor Orthopedic and Spine - Facilities opened post-2010: AMH Cath Labs, Texas Rehabilitation Hospital of Fort Worth, Texas Health Harris Methodist Hospital Alliance

Rockwall Regional Hospital Treat/ Treat/ Treat/ Treat/ Release Treat/ Release Release Release No Release Emergency 2012 Emergency Room Acuity Year Admitted Critical Acuity High Acuity Low Acuity Acuity Total Room Total T/R No Acuity, Admitted, T/R 2011 17,136 605 60,439 13,760 31,972 106,776 123,912 8.9% 15.5% Critical 2012* 17,464 504 68,004 18,444 8,523 95,475 112,939 T/R Acuity, Low 0.5% Annual Chg 328 (101) 7,565 4,684 (23,449) (11,301) (10,973) Acuity, 2011 13.8% 0.6% 56.6% 12.9% 29.9% 100.0% 100.0% 19.3% 2012* 15.5% 0.5% 71.2% 19.3% 8.9% 100.0% 100.0% Annual Chg 1.9% -16.7% 12.5% 34.0% -73.3% -10.6% -8.9%

Total 2012 Community, Reported Emergency Room Visits per 1,000 Population 272.0 T/R Texas, Emergency Room Visits per 1,000 Population 385.6 High U.S., Emergency Room Visits per 1,000 Population 411.3 Acuity, 71.2%

Community % U.S. % Community/ Reason for Emergency Visit 2012* Distribution Distribution U.S. Variance The community visit rate 1 Injury and poisoning 21,879 22.9% 22.0% 0.9% per 1,000 people is lower 2 Symptoms, signs & factors influencing health 12,085 12.7% 19.9% -7.2% than the state average. 3 Diseases of the lung and respiratory system 12,056 12.6% 12.3% 0.3% 4 Diseases of the nervous system 9,040 9.5% 4.8% 4.7% Note that a reported 5 Diseases of the heart and circulatory system 8,221 8.6% 3.5% 5.1% emergency room visit rate 6 Diseases of the genitourinary system 7,067 7.4% 5.0% 2.4% 7 Diseases of the stomach and digestive system 5,884 6.2% 5.9% 0.3% higher than the state is a 8 Diseases of muscles, bone & connective tissue 5,344 5.6% 6.0% -0.4% concern however, if the rate 9 All Other 4,580 4.8% 8.6% -3.8% is lower it could be 10 Diseases of the skin 3,276 3.4% 3.6% -0.2% 11 Mental Illness 2,808 2.9% 3.5% -0.6% attributable to a few smaller 12 Infectious and parasitic diseases 1,621 1.7% 3.4% -1.7% facilities not reporting its 13 Nutritional, metabolic/immunity disorders 1,613 1.7% 1.6% 0.1% emergency room visits. Treat/Release Total 95,475 100% 100% 0.0%

Data Sources: Emergency department acuity data, for Jan-Dec 2011 and Jan-Sep 2012, from Dallas Fort Worth Hospital Council. U.S. distributions from National Hospital Ambulatory Medical Care Survey: 2009 ED Summary Tables. Zip code population estimates and projections retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. Note: Emergency Department (ED) acuity is meant to show the mix of persons that visit the ED for serious illness, such as heart attack, as opposed to those that visit the emergency for reasons that could be treated outside the ED, such as an ear ache. 27 *Note: 2012 was annualized from Jan-Sep 2012 visits. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Provider Supply/Demand Dentists, primary care doctors and psychiatrists The community shows a shortage in dentistry, primary care and psychiatry. When considering the limited number of providers accepting Medicaid and/or Medicare the doctor shortage increases. Family Internal Total Primary Zip Population Dentist Practice Medicine Pediatrics Care Doctors Psychiatrist 75032 30,257 40 18 2 3 23 0 75043 58,923 25 11 2 5 18 0 75048 20,206 10 3 0 0 3 0 75087 30,217 34 8 3 2 13 3 75088 24,972 22 9 5 6 20 0 75089 31,861 4 4 1 0 5 0 75098 52,861 12 6 2 3 11 0 75126 36,917 5 4 3 1 8 0 75132 0 0 0 0 0 0 0 75135 6,253 0 0 0 0 0 0 75160 24,436 7 10 4 1 15 17 75164 0 0 0 0 0 0 0 75166 2,801 1 0 0 0 0 0 75173 5,611 0 0 0 0 0 0 75182 5,454 5 0 0 0 0 0 75189 24,133 1 2 0 1 3 0 75401 19,092 8 0 0 0 0 0 75402 16,358 11 0 0 0 0 0 75442 9,660 3 3 0 0 3 0 75474 15,269 5 0 0 0 0 0 Total 415,281 193 78 22 22 122 20

Provider need per 100,000 population 60.0 22.5 19.0 13.9 55.4 5.7 Providers required for community 249.2 93.4 78.9 57.7 230.1 23.7

Surplus (Shortage) (56.2) (15.4) (56.9) (35.7) (108.1) (3.7) The shortage could be greater considering: 31% of Texas doctors are not Not applicable (38.9) (63.5) (42.3) (144.8) (9.7) accepting new Medicaid patients 1 69% of Texas doctors do not accept Not applicable (38.9) (63.5) (42.3) (144.8) (9.7) Medicaid at all 2 17% of US physicians are not Not applicable (28.7) (60.6) (39.5) (128.8) (7.1) accepting new Medicare patients 1

Data Sources: Physician counts from American Medical Association, Texas State Board of Medical Examiners and Texas State Board of Dental Examiners. Physician need population ratios from Solucient and DGA, and dentist population ratios from Kaiser Family Foundation State Health Facts. Population estimates and projections were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven. 1 Decker, Sandra L. In 2011 Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs. 2012; 31 (8): 1673-1679. 2 TMA March 2012 Survey of Texas Physicians: Preliminary Findings Availability. 2012. Texas Medical Association. Available http://www.texmed.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=24760&libID=22396 Last accessed March, 22, 2013. 28 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Health Professional Shortage Areas Primary medical care

Health Professional Shortage Areas (HPSAs) are designated by the U.S. Department of Health and Human Services as having shortages of primary medical care, health providers and may be geographic (a county or service area), demographic (low income population) or institutional (federally qualified health center or other public facility). Shortages are defined by population-to-physician ratios, or by other indicators including - but not limited to - poverty rate, infant mortality rate, and physical distance from care. Geographic or demographic shortage areas are shown on map HPSA Name HPSA Type County in red. Reported institutional Dallas County Health Department Comprehensive Health Center Dallas Health Services of North Texas, Inc. Comprehensive Health Center Dallas HPSAs are listed. Los Barrios Unidos Communty Health Center Comprehensive Health Center Dallas Mission East Dallas (Medical) and Metroplex Project Comprehensive Health Center Dallas MLK Jr Family Center Comprehensive Health Center Dallas Community Health Services Agency Comprehensive Health Center Hunt Federal Correctional Institution - Seagoville Correctional Facility Dallas Urban Inter-Tribal Center of Texas Native American Tribal Population Dallas Agape Clinic Other Facility Dallas Parkland Ambulatory Care Clinic Other Facility Dallas Parkland Hospital Ob/Gyn ICC Other Facility Dallas Parkland Internal Medical Clinic Other Facility Dallas Low Income - Hunt County Population Group Hunt Data Sources: U.S. Department of Health and Human Services Health Resources and Services Administration. 29 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Health Professional Shortage Areas Mental health

Health Professional Shortage Areas (HPSAs) are designated by the U.S. Department of Health and Human Services as having shortages of mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (federally qualified health center or other public facility). Shortages are defined by population-to-physician ratios, or by other indicators including - but not limited to - poverty rate, infant mortality rate, and physical distance from care. Geographic or demographic shortage areas are shown on map in red. Reported institutional HPSAs are listed.

Data Sources: U.S. Department of Health and Human Services Health Resources and Services Administration. 30 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Providers Supply Facilities dedicated to serving the population in need Ten (10) facilities throughout the community serve the population in need: • 1 charitable community clinics • 3 federally qualified health centers • 4 general hospitals (community hospitals with emergency departments) • 1 county health immunization clinic • 1 psychiatric hospital

PROVIDER TYPE FACILITY NAME STREET ADDRESS CITY STATE ZIP COMMUNITY CLINIC HELPING HANDS - ROCKWALL 102 S. FIRST STREET ROCKWALL TX 75087 FQHC COMMUNITY HEALTH SERVICE AGENCY COMMUNITY HEALTH CENTER4311 B WESLEY STREET GREENVILLE TX 75401 FQHC COMMUNITY HEALTH SERVICE AGENCY DENTAL CLINIC 3600 CADDO STREET GREENVILLE TX 75401 FQHC FARMERSVILLE FAMILY MEDICAL CENTER 111 N. JOHNSON STREET FARMERSVILLE TX 75442 HOSPITAL HUNT REGIONAL MEDICAL CENTER GREENVILLE 4215 JOE RAMSEY BOULEVARD GREENVILLE TX 75401 HOSPITAL LAKE POINTE MEDICAL CENTER 6800 SCENIC DRIVE ROWLETT TX 75088 HOSPITAL TEXAS HEALTH PRESBYTERIAN HOSPITAL ROCKWALL 3150 HORIZON ROAD ROCKWALL TX 75032 HOSPITAL TEXAS REGIONAL MEDICAL CENTER AT SUNNYVALE 231 SOUTH COLLINS ROAD SUNNYVALE TX 75182 IMMUNIZATIONS HUNT COUNTY HEALTH DEPARTMENT 4815B KING STREET GREENVILLE TX 75401 PSYCH HOSPITAL TERRELL STATE HOSPITAL 1200 EAST BRIN TERRELL TX 75160

Data Sources: National Association of Free and Charitable Clinics. Texas Department of State Health Services, Health Facility Program. Texas Department of State Health Services, Texas Primary Care Office. 31 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Facilities Dedicated to Serving the Population In Need

Many of the facilities are in areas identified to be of the most need (shown in red).

Data Sources: National Association of Free and Charitable Clinics. Texas Department of State Health Services, Health Facility Program. Texas Department of State Health Services, Texas Primary Care Office. Zip code population estimates and projections were retrieved by Texas Health Resources Strategy and Business Planning Department from Truven.

32 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Rockwall Regional Hospital Area Selection of community assets for the underserved Health Care Related: Other Resources: Rockwall Regional Hospital Rockwall County Helping Hands Rockwall County Helping Hands • Assistance and Referral Program • Health Center, a primary care clinic • The Thrift Stores of Helping Hands Community Health Service Agency - • Food Pantry Federally Qualified Health Center Lone Star CASA (FQHC) This Is Your Season Ministries • Community Health Center Habitat for Humanity • Dental Clinic Meals on Wheels - Rockwall County Farmersville Family Medical Center – Committee on Aging Federally Qualified Health Center Lake Pointe Church Rockwall, TX (FQHC) Hunt County Health Department - Immunizations Rockwall County Indigent Health Care office • Determines eligibility for health care services • Processes provider's bills • Makes referrals to other agencies

33 Source: Texas Health Resources Community Health Improvement Department. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Secondary Data Assessment: • Review of other recent Community Health Needs Assessments Summary of Key Issues Identified in Other Recent Area Community Health Needs Assessments

The health issues below are those which were ranked highest for recommended action or noted as key community needs. This is not intended to be a comprehensive list.

Regional Regional Regional 2012 2011 Health Health Health Dallas 2011 ABC: 2012 ABC: Denton 2012 Cook Partnership 9 Partnership 10 Partnership 18 County Dallas North County, Children's Key Health Issues Identified and/or Prioritized CHNA Report CHNA Report CHNA Report CHNA County Texas United Way CCHAPS Access: Provider Supply x x x x x x x x Mental Health x x x x x x x Substance Abuse x x x x x x Awareness, literacy, navigation x x x x x Preventive/Wellness x x x x x Social Determinants x x x x x Nutrition, Physical Activity and Obesity x x x x Chronic Disease x x x x Injury and Violence x x x x Other Clinical/Preventive x x x Oral health x x Maternal, Infant, and Child Health x x Cancer x Environmental Quality x

Notes: Key health issues sorted by count of inclusion within other Community Health Needs Assessments. Regional Health Partnership 9 CHNA Report includes Dallas, Denton and Kaufman counties. Regional Health Partnership 10 CHNA Report includes Ellis, Erath, Hood, Johnson, Parker, Tarrant and Wise counties. Regional Health Partnership 18 CHNA Report includes Collin and Rockwall counties. 2012 Dallas County CHNA includes Dallas County. 2011 ABC: Dallas County includes Dallas County. 2012 ABC: North Texas includes Collin and Denton counties. 2011 Denton County, United Way includes Denton County. 2012 Cook Children's CCHAPS includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties. 35 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Reference List for Recent Area Community Health Needs Assessments

Children’s Medical Center. Beyond ABC: Assessing Children’s Health in Dallas County. Available http://www.childrens.com/Assets/Documents/aboutUs/beyond-ABC-2011.pdf. (2011). Last accessed February 15, 2013. Children’s Medical Center. Beyond ABC: Assessing Children’s Health in the North Texas Corridor. Available http://www.childrens.com/Assets/Documents/aboutUs/BABC-2012-%20FA.pdf. (2012). Last accessed February 15, 2013. Collins, Summer. Regional Health Partnership 9: Community Needs Assessment Report. Available http://www.parklandhospital.com/whoweare/section- z115/pdf/Final_1115_Needs_Assessment_Report_5.22.12.pdf. (2012). Last accessed February 15, 2013. Cook Children’s Center for Children’s Health. The Decade of the Healthy Child : Healthy Children 2020. Available https://www.centerforchildrenshealth.org/en-us/Pages/default.aspx. (2012). Last accessed February 15, 2013. Edwards, J., Pickens, S., Schultz, L., Erickson, N., Dykstra, D. Horizons: The Dallas County Community Health Needs Assessment. Dallas, TX: Dallas County Health and Human Services and Parkland Health and Hospital System. Available http://www.dallascounty.org/department/hhs/documents/DCCHNA- PublicCommentDraft.pdf. (2012). Last accessed February 15, 2013. Regional Healthcare Partnership 18. Community Needs Assessment. Available http://www.co.collin.tx.us/healthcare_services/RHP18_Community_Needs.pdf. (2012). Last accessed February 15, 2013. Salsberry, David. RHP Lead Contact. Regional Healthcare Partnership Plan: Region 10. Available http://www.jpshealthnet.org/uploadedFiles/Region%2010%20RHP%20Plan%20Final.pdf. (2012). Last accessed February 15, 2013. United Way of Denton County. 2011 Community Assets and Needs Assessment. Available http://www.unitedwaydenton.org/activities/community-assets-needs-assessment. (2011). Last accessed February 15, 2013.

Eleven (11) persons from the community completed the survey summarized below, with responses ranging 1-5, where 1 is “strongly disagree” and 5 is “strongly agree”. The four issues of most concern to survey respondents appear to be: • Lack of adequate resources for indigent (low-income people) in the community • Language and culture as a barrier to access • Cost as a barrier to access in the community (tied for 3rd) • Transportation as a barrier to access (tied for 3rd)

Most favorable Rockwall Regional Indicator Score Hospital Average Community members are informed and educated about health issues. 5 2.9 Community members know where to go for needed health services. 5 2.9 There are adequate health resources for children in the community. 5 2.6 There are adequate health resources for the elderly in the community. 5 3.1 There are adequate health resources for the indigent in the community. 5 2.2 There are adequate health resources for other vulnerable populations. 5 2.4 Supply (number, type of providers) is a barrier to access in this community. 1 3.5 Cost of care is a barrier to access in this community. 1 3.6 Transportation is a barrier to access in this community. 1 3.6 Language and culture are a barrier to access in this community. 1 3.7 Previous negative experiences are a barrier to access in this community. 1 2.6

ACKNOWLEDGED STRENGTHS GAPS IN SERVICES/CARE • Providers: • Transportation to/from health services • Helping Hands Health Center • Fewer providers accepting Medicaid and • Rockwall Regional Hospital Medicare patients • Strong, close knit community. Remarkable • Mental health network of providers and “can do” attitude • Drug and alcohol treatment especially for youths • Partnerships: • Preventive dental care for adult Medicaid and • Collaboration between Helping Hands and uninsured adult and children Schools, YMCA and Hospital to provide Wellness and Prevention programs • There may not be enough hospital beds during • Lakepointe Medical Center and Texas Health peak seasons, resulting in overflowing exploring options to expand community services emergency department

SUGGESTIONS AND OPPORTUNITIES COMMUNITY CONCERNS • Educate community about services available • Lack of access for Medicaid and uninsured within the community • Resultant increase in emergency department use • Proper use of emergency department and • Undocumented citizens who utilize services available alternatives • Limited MRI and specialty care services • Helping Hands does serve Medicare patients • Growth in 65+ population, but lack of providers • Wellness and prevention that accept Medicare • Explore an additional community clinic or • Concern about school age suicide rate and wellness center to serve continued growth in limited support in this area uninsured and underinsured populations • Limited transportation-no public transportation

Melody L. Hail, Director of Development - Rockwall County Helping Hands Sherry Hamm, Director of Assistance & Referral - Rockwall County Helping Hands Margo Nielson, Executive Director - Rockwall County Helping Hands John William Howard - Board of Governors Dana K. Macalik, President - Rockwall Area Chamber of Commerce Cheryl Dunlop, Director Administrative Services - City of Rockwall Nichol Smithers, Health Services Coordinator - Rockwall Independent School District Gary Bonacquisti, M.D., Chief Medical Officer - Rockwall City Health Authority Kim West, Director of Counseling - Rockwall Independent School District David Lensch, M.D., Health Officer - City of Rockwall Nikki Mutschler, Marketing Director- Rockwall Regional Hospital Melanie Mayfield, Marketing Coordinator- Rockwall Regional Hospital

40 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Notes to the Study: • How the assessment was conducted including data sources • Process for consulting with people representing the community’s interest • Process for identifying and prioritizing health needs and services • Gaps that limited ability to assess the community’s health needs

How the Assessment was Conducted

Texas Health Resources’ Community Health Needs Assessment was a six-month collaborative process, led by Texas Health’s Community Health Improvement Department and entity community advocates with significant input from Texas Health’s Community Health Advisory Council. Vast amounts of quantitative and qualitative data were collected, refined and analyzed. Approximately 200 community members provided invaluable information, data, and feedback.

Texas Health utilized the following approach to complete a community health needs assessment: • Create the Vision for the Community Health Needs Assessment • Define the Scope, Including the Zip-Code Level Service Area • Identify Key Demographics of Service Area • Identify Services Provided by Area Health Resources (Supply) • Identify Key Health Needs by Service Area (Demand) • Identify Gaps in Services Provided • Develop Community Needs Model, Including Criteria for Prioritizing Needs • Prioritize Community Needs, Based on Data and Model Criteria • Develop Strategies to Address Needs • Outline Actionable Objectives, Timelines and Implementation Process

Secondary data used throughout this analysis was obtained from more than 30 sources, and is outlined in detail on the following slides. 42 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Secondary Data Sources

Demographic Assessment Education Levels of the Population: ACS Educational Attainment by Degree-Level and Age-Group ( U.S. Census Bureau, 2011 American Community Survey). National Information Center for Higher Education Policymaking and Analysis. (2011). Available http://www.higheredinfo.org/dbrowser/index.php?submeasure=344&year=2011&level =nation&mode=data&state=0. Last accessed March 21, 2013. Texas 2012 population projections from 2010 census. Texas State Data Center. (2013). Available http://txsdc.utsa.edu. Last accessed February 15, 2013. Texas Health Resources. (2012). Language Access Service Data 2012. Texas Health Resources Diversity and Inclusion Department. Retrieved on January, 28 2013. Texas Hospital Inpatient Discharge Public Use Data File, Q1-Q4 2010. Texas Health Care Information Council, Austin, Texas. (2012). Texas population distributions by age and gender. Texas State Data Center. (2013). Available http://txsdc.utsa.edu. Last accessed January 28, 2013. Texas and U.S. population distributions by race and ethnicity. Kaiser Family Foundation’s State Health Facts. (2012). Available http://www.statehealthfacts.org. Last accessed January 28, 2013. The Nielsen Company, Truven. Average and median income. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. The Nielsen Company, Truven. High school graduation percentages. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. The Nielsen Company, Truven. Inpatient payer mix percentages. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. The Nielsen Company, Truven. Population 2012 estimates and 2017 projections. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. The Nielsen Company, Truven. Uninsured estimates. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. U.S. Census Bureau. Poverty and uninsured estimates. Available http://www.census.gov. Last accessed January 28, 2013. U.S. Census Bureau. U.S. population distributions by age, gender, and race. Available http://www.census.gov. Last accessed January 28, 2013. 43 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Secondary Data Sources

Community Access and Health Status Indicators Behavioral Risk Factor Surveillance System. (2012). Texas Department of State Health Services. Available http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm. Last accessed February 12, 2012. Community health status indicators. CHSI 2009. U.S. Department of Health and Human Services. Available http://wwwn.cdc.gov/CommunityHealth. Last accessed November 17, 2012. County Health Rankings and Roadmaps. County Health Rankings Project. (2012). Available http://www.countyhealthrankings.org. Last accessed November 20, 2012. Dallas Fort Worth Hospital Council. Prevention Quality Indicator data, for 2010 and 2011, by zip code. Retrieved by Dallas Fort Worth Hospital Council from internal databases. Health facts profiles for individual counties. (2012). Texas Department of State Health Services. Available https://www.dshs.state.tx.us/chs/cfs/Texas-Health-Facts-Profiles.doc. Last accessed November 29, 2012. Percentage by county of illiterate adult Texans. (2009). Texas Center for the Advancement of Literacy & Learning. Available http://www-tcall.tamu.edu/docs/09illitmap.html. Last accessed November 20, 2012. Texas Department of State Health Services. Texas health status indicators 2007-2010. Retrieved by Texas Department of State Health Services from Behavioral Risk Factor Surveillance System (BRFSS) database. Texas Department of State Health Services. Texas mortality and natality data 2010. Retrieved by Texas Department of State Health Services Center for Health Statistics and Vital Statistics Units from Texas vital statistics database. Texas Department of State Health Services. Texas substance abuse treatment statistics 2009. Retrieved by Texas Department of State Health Services Mental Health and Substance Abuse Division from mental health and substance abuse databases. Texas Medicaid enrollment statistics. Texas Health and Human Services Commission. Available http://www.hhsc.state.tx.us/research. Last accessed November 27, 2012. The Nielsen Company, Truven. 2010-2012 PULSE™ Healthcare Survey health status indicators. (2012). Retrieved by Texas Health Resources Strategy and Business Planning Department. Unemployment statistics. U.S. Department of Labor Bureau of Labor Statistics. Available http://www.bls.gov. Last accessed February 18, 2013.

U.S. Federal Poverty Level guidelines. U.S. Census Bureau. Available http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml. Last accessed February 19, 2013. U.S. statistics. Centers for Disease Control and Prevention, Fast Stat reports. (2013). Available http://www.cdc.gov/DataStatistics. Last accessed February 14, 2013.

Supply and Demand Utilization Dallas Fort Worth Hospital Council. Emergency Department acuity data, for Jan-Dec 2011 and Jan-Sep 2012. Retrieved by Dallas Fort Worth Hospital Council from internal databases. Directory of Community Clinics. National Association of Free and Charitable Clinics. Available http://nafcclinics.org. Last accessed November 21, 2012. Directory of Physician Specialties. American Medical Association. Available http://www.redimeddata.com. Last accessed November 14, 2012. Directory of Primary Care Clinics. (2012). Texas Department of State Health Services State of Texas Primary Care Office. Available http://www.dshs.state.tx.us/phc/locator/locator.shtm. Last accessed November 14, 2012. Directory of Texas Dentists. Texas State Board of Dental Examiners. Available http://www.tsbde.state.tx.us. Last accessed November 20, 2012. Directory of Texas Health Facilities. (2013). Texas Department of State Health Services. Available http://www.dshs.state.tx.us/hfp/apps.shtm. Last accessed February 1, 2013. Directory of Texas Physicians. Texas State Board of Medical Examiners. Available http://www.tmb.state.tx.us. Last accessed November 21, 2012. Directory of Urgent Care Centers. American Academy of Urgent Care Medicine. Available http://aaucm.org/Patients/FindUrgentCareCenter. Last accessed November 21, 2012. Directory of Urgent Care Centers. (2012). Urgent Care Association of America. Available http://www.ucaoa.org/ucaoa_orgs.php. Last accessed November 21, 2012. Directory of Federally Qualified Health Centers. (2012). Texas Department of State Health Services, Texas Primary Care Office. Available http://www.dshs.state.tx.us/chpr/fqhcmain.shtm. Last accessed November 14, 2012.

Health Professional Shortage Areas. (2013). U.S. Department of Health and Human Services Health Resources Administration. Available http://hpsafind.hrsa.gov. Last accessed January 22, 2013. JPS Health Clinic locations. JPS Health System website. Available http://www.jpshealthnet.org. Last accessed January 7, 2013. Parkland Health System Clinic locations. Parkland Health and Hospital System website. Available http://www.parklandhospital.com. Last accessed January 7, 2013. Ten leading principal reasons for emergency department visits, by patient age and sex: United States. National Centers for Health Statistics: National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Table 10. Center for Disease Control and Prevention. Available http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf. Last accessed February 19, 2013.

Other References Decker, Sandra L. In 2011 Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs. 2012; 31 (8): 1673-1679. Number, rate, and average length of stay for discharges from short-stay hospitals, by age, region, and sex: United States, 2010. National Centers for Health Statistics: National Hospital Discharge Survey. Center for Disease Control and Prevention. Available http://www.cdc.gov/nchs/data/nhds/1general/2010gen1_agesexalos.pdf. Last accessed March, 22, 2013. Physician Community Requirements in the 21st Century: The 2003 Physician to Population Ratios. Solucient. Simmons, H.J., Harris, John M. Community-Based Physician Need Planning Methodologies Evolve. Health Care Strategic Management. 2004; 22(12). DGA Article – Physician Need Methodologies. TMA March 2012 Survey of Texas Physicians: Preliminary Findings Availability. 2012. Texas Medical Association. Available http://www.texmed.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=24760&libID=22396. January 23, 2013.

During December 2012 and January 2013, interviews were conducted with approximately 200 persons representing the community’s interests.

Information and data were gathered using two different methods: • Open-ended discussions, led by Premier, Inc., aimed at soliciting input from the interview participants as to community health resources, as well as the health needs of the community. • Likert surveys, containing 11 statements regarding community health for which participants ranked their agreement or disagreement.

Drawing from the data elements analyzed and presented in each entity community health needs assessment, Texas Health Resources has developed a model to identify and prioritize health needs. At its most basic level, the model outlines all identified health issues in rows, and marks in columns each entity impacted by that specific issue. The specific issues were also grouped into health categories adapted from the Healthy People 2020 categories. Any issue not meeting threshold levels (e.g., a minimum number of indicators showing a problem and/or a minimum number entities having raised that issue) were removed from subsequent analysis. Remaining issues were assessed using criteria designed to rank, or prioritize the issues. Texas Health used the resulting rankings to select which health needs will be addressed over the next three years. Once selected, the organization developed strategies and initiatives aimed at impacting those gaps.

The vast majority of secondary data required to assess community need was available for Texas Health Resources’ analysis.

In certain instances, however, data was not available at Texas Health’s preferred level of detail. Specific examples of this include: • Zip Code Level Data – Some health indicators and behavioral factors are published at the county level, not the zip code level, which prohibited Texas Health from analyzing these data for an entity’s defined service area. Examples include sexually transmitted disease rates, obesity rates, literacy rates, and many others. These data elements have been included in the community health needs assessment data as reference points but county-level indicators were not used in the prioritization of health needs. • Data for Uninsured and Underinsured – A significant finding of this study is that access to health services is limited for the uninsured and underinsured. This issue was mentioned numerous times by a wide range of participants. However, quantifying this issue is difficult, if not impossible. There is no publicly available source of data to identify providers who accept uninsured patients or providers who accept patients with Medicare or Medicaid. Estimates have been included in the physician supply and demand section of this study, but these are estimates only and do not provide the ideal level of specificity. • Lack of Efficacy –Texas Health prefers to utilize evidence based programs to improve the health of the community it serves. However, there are few existing studies that measure, evaluate and/or report the effectiveness of preventative wellness programs and initiatives. Texas Health will proceed with information currently available and supplement with internal expertise as needed.

Note: Texas Health does not believe the limitations outlined above impacted Texas Health’s ability to reach reasonable conclusions regarding the health needs of the 49 community. PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Appendix Demographics Needs Summary Population of focus – Grading System

Demographic information was collected from Truven Health Analytics for the four below data elements listed below: • 2012 total population • 5 year population growth 2012-2017 • Median household income • Age 18+ percent uninsured Each of the four elements were ordered either ascending or descending depending upon whether a higher need was suggested: • There is more need in densely populated areas • There is more need in areas of high population growth • There is more need in areas of low income • There is more need in areas with high percentages of uninsured These rankings are summed in total and then averaged to obtain a “score” which is itself then ranked. Considering these four key factors, the associated maps show the areas of highest need in darker red to areas of minimal need in dark blue.

PROVIDER TYPE FACILITY NAME STREET ADDRESS CITY STATE ZIP ASC BAYLOR SURGICARE AT HEATH 6435 SOUTH FM 549 SUITE 101 HEATH TX 75032 ASC BELTLINE SURGERY CENTER LLC 2858 NORTH BELTLINE ROAD #100 SUNNYVALE TX 75182 ASC ROCKWALL AMBULATORY SURGERY CENTER 825 WEST YELLOW JACKET LANE ROCKWALL TX 75087 ASC SPECIALTY SURGERY CENTER 3900 JOE RAMSEY BLVD GREENVILLE TX 75401 ASC THR/STT ROCKWALL ASC LLC 3142 HORIZON RD. STE 100 ROCKWALL TX 75032 BIRTHING CENTER HEAVENLY HANDS BIRTHING CENTER PLLC 909 NORTH GOLIAD ROCKWALL TX 75087 COMMUNITY CLINIC HELPING HANDS - ROCKWALL 102 S. FIRST STREET ROCKWALL TX 75087 DIALYSIS DIALYSIS CARE OF GREENVILLE 4805 WESLEY STREET GREENVILLE TX 75401 DIALYSIS FMC DIALYSIS SERVICES TERRELL 351 SOUTH VIRGINIA STREET TERRELL TX 75160 DIALYSIS FRESENIUS MEDICAL CARE OF ROWLETT 3801 LAKEVIEW PARKWAY SUITE 100 ROWLETT TX 75088 DIALYSIS LIBERTY DIALYSIS ROCKWALL LLC 2850 RIDGE ROAD ROCKWALL TX 75087 DIALYSIS ROCKWALL DIALYSIS CENTER 2455 RIDGE ROAD SUITE 101 ROCKWALL TX 75087 DIALYSIS UNITED DIALYSIS CARE DBA GREENVILLE DIALYSIS 4309 RIDGECREST ROAD SUITE 100 GREENVILLE TX 75402 FQHC COMMUNITY HEALTH SERVICE AGENCY COMMUNITY HEALTH CENTER 4311 B WESLEY STREET GREENVILLE TX 75401 FQHC COMMUNITY HEALTH SERVICE AGENCY DENTAL CLINIC 3600 CADDO STREET GREENVILLE TX 75401 FQHC FARMERSVILLE FAMILY MEDICAL CENTER 111 N. JOHNSON STREET FARMERSVILLE TX 75442 HOSPITAL HUNT REGIONAL MEDICAL CENTER GREENVILLE 4215 JOE RAMSEY BOULEVARD GREENVILLE TX 75401 HOSPITAL LAKE POINTE MEDICAL CENTER 6800 SCENIC DRIVE ROWLETT TX 75088 HOSPITAL RENAISSANCE HOSPITAL TERRELL 1551 HIGHWAY 34 SOUTH TERRELL TX 75160 HOSPITAL TEXAS HEALTH PRESBYTERIAN HOSPITAL ROCKWALL 3150 HORIZON ROAD ROCKWALL TX 75032 HOSPITAL TEXAS REGIONAL MEDICAL CENTER AT SUNNYVALE 231 SOUTH COLLINS ROAD SUNNYVALE TX 75182 IMMUNIZATIONS HUNT COUNTY HEALTH DEPARTMENT 4815B KING STREET GREENVILLE TX 75401 PSYCH HOSPITAL GLEN OAKS HOSPITAL 301 EAST DIVISION STREET GREENVILLE TX 75402 PSYCH HOSPITAL TERRELL STATE HOSPITAL 1200 EAST BRIN TERRELL TX 75160 URGENT CARE ACUTE KIDS URGENT CARE 2701 CROSS TIMBERS SUITE 232 FLOWER MOUND TX 75032 URGENT CARE CARE UNITED MEDICAL CENTER 2344 GREENCREST BLVD ROCKWALL TX 75087 URGENT CARE CARE UNITED MEDICAL CENTER 426 O LD FM548 SUITE 124 FORNEY TX 75126 URGENT CARE CARENOW 565 W EST I-30 GARLAND TX 75043 URGENT CARE LAKE POINT URGENT CARE 1005 W. RALPH HALL ROCKWALL TX 75032 URGENT CARE MICHAEL D. MIXON, M.D., P.A. 500 T URTLE COVE BLVD STE 110 ROCKWALL TX 75087 URGENT CARE MINUTECLINIC (INSIDE CVS) 2400 N. GOLIAD ST ROCKWALL TX 75087 URGENT CARE MINUTECLINIC (INSIDE CVS) 750 W EST FM 544 WYLIE TX 75098 URGENT CARE ROCKWALL URGENT CARE 810 E. RALPH HALL ROCKWALL TX 75032

Data Sources: National Association of Free and Charitable Clinics. Texas Department of State Health Services, Health Facility Program. Texas Department of State Health Services, Texas Primary Care Office. 52 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Health Professional Shortage Areas Dental care

Health Professional Shortage Areas (HPSAs) are designated by the U.S. Department of Health and Human Services as having shortages of dental providers and may be geographic (a county or service area), demographic (low income population) or institutional (federally qualified health center or other public facility). Shortages are defined by population-to-physician ratios, or by other indicators including - but not limited to - poverty rate, infant mortality rate, and physical distance from care. Geographic or demographic shortage areas are shown on map in red. Reported institutional HPSAs are listed.

HPSA Name HPSA Type County Dallas County Health Department Comprehensive Health Center Dallas Los Barrios Unidos Communty Health Center Comprehensive Health Center Dallas Mission East Dallas (Medical) and Metroplex Project Comprehensive Health Center Dallas MLK Jr Family Center Comprehensive Health Center Dallas Community Health Services Agency Comprehensive Health Center Hunt Federal Correctional Institution - Seagoville Correctional Facility Dallas Urban Inter-Tribal Center of Texas Native American Tribal Population Dallas Deharo Saldivar Dental Center Other Facility Dallas East Dallas Dental Center Other Facility Dallas Parkland Dental Center Other Facility Dallas Data Sources: U.S. Department of Health and Human Services Health Resources and Services Administration. 53 PROPRIETARY & CONFIDENTIAL – © 2012 PREMIER INC. Community Health Needs Assessment: Strategic Implementation Plan

Rockwall Regional Hospital (Texas Health Rockwall) Overview and Contents

• CHNA Needs Identification • CHNA Needs Prioritization – Health Issues to be Addressed by the Entity – Health Issues not to be Addressed by the Entity • Strategies Developed to Address Health Issues • Strategy Implementation Logic Model • Checklist of Additional Implementation Items

Needs Identification and Prioritization

• Identification of the community’s significant Vast amounts of quantitative and qualitative data were collected, refined and analyzed during this health needs draws from more than 90 data Community Health Needs Assessment process. elements presented in the CHNA. These Detailed data is presented in the CHNA. The chart below summarizes the most significant health include both quantitative data (health status issues facing the Texas Health Rockwall community. indicators, use rates, etc..) and qualitative data gathered during meetings with community representatives. • The data points have been placed in a model. This model outlines all identified health issues and then groups the specific issues into health categories adapted from the Healthy People 2020 categories. • Any issue not meeting threshold levels (e.g., a minimum number of indicators showing a problem and/or a minimum number entities having raised that issue) were removed from subsequent analysis. • The findings from Texas Health Rockwall are shown on the right. In addition, the model allows Texas Health Resources to assess all of its facilities and service areas at once. Needs Identification and Prioritization

Issue Impact • Based on a comprehensive analysis of all Prioritization Summary Score Need Score Score Texas Health’s service area, Texas 1 Access: Provider Supply 2.65 1.45 1.20 Health’s leadership has approved a strategic focus for 2014-2016 to address: 1 Awareness, literacy, navigation 2.65 1.45 1.20 – Chronic Disease 3 Mental Health 2.55 1.65 0.90 – Awareness, Literacy and Navigation

4 Chronic Disease 2.40 1.65 0.75 • Specific strategies aimed at impacting 4 Maternal, Infant, and Child Health 2.40 1.50 0.90 chronic disease and awareness, literacy 6 Injury and Violence 2.35 1.45 0.90 and navigation are outlined later in this Nutrition, Physical Activity, and document. 6 Obesity 2.35 1.45 0.90

6 Oral Health 2.35 1.45 0.90 • Rationale for not developing new strategy 9 Substance Abuse 2.20 1.45 0.75 around the other prioritized issues is detailed on the following slide. This does 9 Other Clinical/Preventive 2.20 1.30 0.90 not mean that Texas Health Rockwall will 11 Cancer 2.00 1.10 0.90 not continue its work in many of the related areas, but rather new strategy will 12 Tobacco 1.85 0.95 0.90 focus on chronic disease and awareness, 13 Social Determinants 1.75 1.30 0.45 literacy and navigation. 14 Transportation 1.55 0.95 0.60 Rationale for Not Adopting New Strategy for Other Issues

Access: Injury and Maternal, Mental Oral Other Social Substance Transportation Provider Violence Infant, and Health Health Clinical/ Determinants Abuse Supply Child Health Preventive

Resource X X X X constraints Lack of X X X expertise

Low priority X X assigned

Lack of effective X X X intervention Need is being X X addressed Continued level of X X X X X X support

Other X CHNA Implementation Strategies: Awareness, Literacy and Navigation (ALN)

• Collaboration and Dissemination of an Area Resource Guide. Texas Health Rockwall, with input from area collaboratives, will develop and disseminate an area resource guide that identifies health services available to the community and outlines where/when/how to access the services. The guide will be made available online and in print and will be used by Texas Health call center staff. • Sponsorship of Area Collaboratives Working to Address ALN. Texas Health Rockwall will assist with increasing awareness, literacy and navigation efforts by maintaining partnerships with the following organizations whose efforts align directly with awareness efforts: Rockwall County, Helping Hands, YMCA, Rockwall ISD, Boys and Girls Club of America and Lakepointe Church.

CHNA Implementation Strategies: Chronic Disease

• Implementation of the Better Choices, Better HealthTM Program. This evidence- based, chronic disease self management program will be rolled out across the system. Texas Health Rockwall will participate by offering individuals to be trained to facilitate on-site classes. The classes can be offered in person at entity locations or can be offered online to the community. • Maintenance of Entity Based Chronic Disease Programs. Texas Health Rockwall will continue to provide a stroke education video that is available for public use at any time. Additionally, diabetes education classes held in collaboration with Helping Hands will remain a key focus. • Sponsorship of Collaboratives Working to Address Chronic Disease. Texas Health Rockwall will continue to work Helping Hands, American Heart Association, American Cancer Society and Rockwall ISD in support of initiatives addressing chronic disease. In partnership with the United Way, Texas Health Rockwall will support a local school part of the Healthy Zone School Recognition Program. Texas Health Rockwall will also work to ensure that future in-kind donations and sponsorships are aligned with the strategic foci for the entity.

Adoption of Implementation Strategies

Rockwall Regional Hospital (Texas Health Rockwall) hereby acknowledges that we have reviewed and approve the CHNA implementation strategies as outlined and acknowledge that there is a budget allocated for such strategies.