DCH 2022 Community Health Needs Assessment : simplebooklet.com

METHODOLOGY INTRODUCTION DCH HEALTH SYSTEM In March of 2023 the DCH Health System will celebrate 100 years of providing quality compassionate health care services to citizens in multiple communities in West Alabama The DCH Health System includes three acute care hospitals including DCH Regional Medical Center Northport Medical Center and Fayette Medical Center DCH Regional Medical Center the largest of the three hospitals is a 583 bed acute care trauma center Northport Medical Center is a 204 bed community hospital and Fayette Medical Center is a 61 bed rural hospital that operates through a long term lease agreement with the DCH Health System All three hospitals are accredited by The Joint Commission and the hospitals have received numerous awards from independent agencies that acknowledge the quality of care provided within the DCH Health System Additionally the DCH Health System operates the Lewis and Faye Manderson Cancer Center located on the campus at DCH Regional Medical Center The DCH Health System is a governmental entity that operates a health system owned by the public and is operated by a nine member Board of Directors two members are appointed by the Tuscaloosa City Council two by the Tuscaloosa County Commission one by the Northport City Council two by the medical staffs of DCH Regional Medical Center and Northport Medical Center and two by the Board itself Each of the members of this diverse group serves a six year term Based on patient origin data the DCH Health System maintains that the defined community is the sevencounty area that the hospitals within the system serve These counties include Tuscaloosa Bibb Fayette Green 2 Hale Lamar and Pickens counties The DCH Health System employs more than 4 700 people and more than 400 physicians privileged to proctice within the health system Services provided by the hospitals include inpatient and outpatient services surgery diagnostics and emergency services As well as many specialty services including pediatrics orthopedics oncology cardiology intensive care rehabilitation and psychiatry The DCH Health System has worked collaboratively with the College of Community Health Sciences at The University of Alabama to provide clinical training sites for students in multiple health care fields Since 1976 more than 260 residents in the Family Practice Residency program have graduated and many of those residents are practicing medicine in West Alabama and other areas of the Southeast The mission of the DCH Health System is We serve to improve the health of our patients and community The vision of the DCH Health System is To be the provider of choice in West Alabama by delivering excellent care The employees and physicians of the DCH Health System give time and energy by volunteering to support community events in schools churches and at various civic events The DCH Health System also provides health fairs and other free health services within the community The System does not deny care to any person regardless of their insurance status or their ability to pay For the years 2020 and 2021 the DCH Health System provided more than 86 million in charity care For the purposes of this report the health care operational centers within the DCH Health System will be hereinafter referred to collectively as the System The Patient Protection and Affordable Care Act regulations allow for facility collaborations under appropriate circumstances DCH Regional Medical

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Center and Northport Medical Center are located within a few miles of each other and offer complimentary and comprehensive services to residents in the seven county area This allows for efficient and effective compliance with the Centers for Medicare and Medicaid Services CMS and the governance standards established by the Joint Commission In 2010 DCH Regional Medical Center and Northport Medical Center received the Sole Community Hospital Designation and as such operate under a single Medicare provider number For this reason this report will reflect a joint Community Health Needs Assessment between DCH Regional Medical Center and Northport Medical Center DCH REGIONAL MEDICAL CENTER The DCH Regional Medical Center is the keystone hospital in the DCH Health System This hospital opened its doors as a 50 bed hospital in 1923 Since then it has expanded multiple times to the 583 bed regional medical center that it is today to meet the constantly growing health care needs of the community it serves DCH offers comprehensive inpatient and outpatient services specialty units and multiple advanced services including oncology cardiology robotic surgery pediatrics and orthopedics It is also West Alabama s premier trauma center providing care to severely injured patients 24 7 with immediate highly trained clinical teams that can provide surgery and other necessary procedures in life threatening situations The Lewis and Faye Manderson Cancer Center is a state of the art cancer facility providing patients with the most highly trained and experienced cancer specialists in the country It is located on the campus of DCH Regional Medical Center DCH Regional Medical Center was the first hospital in Alabama to offer Bloodless Medicine and Surgery a program that provides quality medical care without using blood transfusions This method of care has resulted in shorter hospital stays fewer infections and fewer heart attacks and strokes following surgery According to information provided by the State Health Planning and Development Agency in 2021 DCH Regional Medical Center admitted 19 348 patients had 65 524 emergency room visits and performed 29 775 inpatient 4 and outpatient surgeries and procedures DCH is one of the largest employers in Tuscaloosa County and continually gives back to the community by providing free health services and major sponsorships of events from various civic groups and charities including the American Heart Association March of Dimes American Cancer Society the Arthritis Foundation and the United Way NORTHPORT MEDICAL CENTER In 1992 the Board of Directors of the DCH Health System purchased Northport Medical Center formerly known as AMI West Alabama General Hospital primarily to avoid duplication of high cost equipment and resources and to allow both hospitals to share in the burden of caring for charity patients The Board also desired to provide greater access to more specialized services for residents in the communities of West Alabama This local community hospital provides a broad spectrum of inpatient and outpatient services as well as several specialty services and compliments those services provided at DCH Regional Medical Center North Harbor offers inpatient treatment for adults and geriatric individuals needing psychiatric care The Women s Pavilion is an advanced obstetrical unit providing the latest technology and equipment in a comfortable setting for mothers and their babies The hospital also provides a neonatal intensive care unit with specialized physicians and staff For patients needing advanced high quality orthopedic and neurological care the hospital provides a Rehabilitation Pavilion In 2021 there were more than 7 456 patients admitted to the hospital 40 614 emergency room visits and approximately 5 690 inpatient and outpatient surgeries and procedures performed

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EXECUTIVE SUMMARY The DCH Health System organized a team from DCH Regional Medical Center Northport Medical Center SBC Consulting LLC and the identified community of both hospitals to participate in the 2022 Community Health Needs Assessment CHNA which is required by the Affordable Care Act Section 501 r every three years Team members from SBC Consulting LLC and the DCH Health System facilitated discussions with Stakeholders to identify the issues of health within the community The community identified in the first CHNA in 2013 was deemed to be the seven county geographic area served by both hospitals Demographics disease states socioeconomic status behavioral and physical factors and low income and uninsured populations were considered in order for the CHNA to be diverse and effective The information was presented to the leadership of the DCH Health System and based on the information collected and analyzed three health issues were determined to be priorities An action plan to address the prioritized needs was developed This CHNA is a followup to the 2019 CHNA and is the fourth such CHNA that has been conducted by the DCH Health System Leadership of the DCH Health System formed a diverse stakeholder group to ensure there was proper representation of the community served by the two hospitals The group included representatives of the medically underserved low income and minorities experts in public health government officials religious leaders law enforcement business leaders educators and representatives from DCH Regional Medical Center and Northport Medical Center specialty programs Individual and group meetings were held with stakeholders to identify the health needs within the community over a two month period In addition to the information gathered in the meetings support data was used to assist in identifying the health needs of the community This report also includes pertinent support data from The Alabama Department of Public Health The Robert Woods Johnson Foundation the CDC The American Diabetes Association the Alabama Rural Health Association the US Census Bureau The Alabama Department of Mental Health and others Multiple issues of health were identified through meetings and through public health data Most of the counties in the seven county area had poor health outcomes health behaviors and quality of life compared to other counties in Alabama Additional data showed heart disease cancer stroke diabetes and kidney failure as the leading causes of death in all seven counties Other issues of health identified through the process include Affordable housing for the low income Food insecurity forcing decisions between medications and food Transportation no transportation or poor public transportation Access to care HIV Hepatitis C and other sexually transmitted diseases Mental health suicide isolation depression drug and alcohol abuse Mental health for adolescents no inpatient beds for adolescents Staffing shortages nursing primary care dental care specialists Diabetes obesity Lack of community resources and case management Homelessness 5

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Long wait times in the Emergency Departments ED Slow turn around in the ED ties up ambulance services Lack of ambulance coverage especially in the rural areas Outmigration of patients in the service area to other hospitals outside service area Hospital perception and public grading Lack of internet access in rural areas Cost of childcare Lack of socialization for the homebound elderly Lack of communication skills for those working with the Hispanic population Inflation Domestic violence Gang gun violence Physician recruitment Need for a psychiatry residency program Insufficient bed numbers in the ED Insufficient environmental services staff Lack of discipline in the home High poverty Mental Health Access to Care Diabetes Obesity Cardiovascular Disease all leading to death in the community Since 2013 the DCH Health System has used the CHNA as a guide in its efforts to improve the overall health and quality of life for residents in the community DCH Regional Medical Center and Northport Medical Center have engaged and collaborated with other entities and organizations throughout the service area to share resources and promote a healthy and safe environment for all residents in the service area The DCH Health System and its hospitals continue to provide the highest quality of care in a compassionate setting without regard to race age or the ability to pay This report will include the following The methodology used to identify the health needs A review of the 2019 CHNA Identification of needs Comorbidities in patients leading to death Description of prioritized needs and plans to address those needs Maternal death rate and infant mortality Recognized health needs not addressed Insufficient reading skills for middle school children Written report and plans to monitor Lack of social resources Chronic heart failure Existing resources available to assist in addressing the health needs Need for a freestanding ED Supplemental data Need a patient advocate in the EO Need for the non emergent side of DCH s ED open to accommodate more patients Uninsured patients especially the lack of dental and vision coverage The issues of health identified through this process are consistent with issues of health identified in previous CHNAs After reviewing prior CHNAs and action plans 6 and considering available resources financial feasibility and potential effectiveness the leadership of the DCH System determined that the priorities of the 2022 2024 CHNA should be

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METHODOLOGY METHODOLOGY The DCH Health System enlisted the assistance of SBC Consulting LLC to assist in facilitating and completing the CHNA pursuant to the rules and regulations set forth in the Affordable Care Act DCH Regional Medical Center and Northport Medical Center developed a stakeholder committee representative of the diverse population in the seven county area served by the hospitals The group consisted of business leaders political leaders law enforcement first responders not for profit organizations state agencies and organizations representing the medically underserved low income and minority populations To ensure confidentiality individual and small group meetings were held between the facilitators and the stakeholders to gather input Stakeholders were asked to identify the health needs as seen by them and to suggest methods to address those needs The process was designed to create collaboration between the DCH Health System and the stakeholders with the goal of improving health equity and health outcomes throughout the community The meetings were facilitated by Stephanie Craft with SBC Consulting LLC and Sammy Watson the Director of Community Relations with DCH Health System The meetings took place over multiple days in February March and April of 2022 The Stakeholder Committee consisted of the following members The Stakeholder Committee included the following Bryan Kindred CEO DCH Health System Jennifer Singleton Community Education Manager DCH North Harbor Pavilion David Anderson Director DCH Diabetes and Nutrition Education Center and Staff Karen Thompson Jackson PhD CEO Temporary Emergency Services of Tuscaloosa Rob Robertson Probate Judge Tuscaloosa County Mark Sullivan Executive Vice President Bryant Bank Linda Forte PhD Retired Nursing Educator Cynthia Burton CEO Community Service Programs David Gay CEO Maude Whatley Pastor Beulah Baptist Church and DCH Health System Board member Lynn Armour Executive Director Good Samaritan Clinic Northport AL Richard Friend MD Dean of College of Community Health Sciences University of Alabama Bobby Herndon Mayor of Northport Chris Cox PhD Interim President and Johnathan Koh PhD Dean of Workforce and Economic Development Shelton State Community College RaSheda Workman VP for Strategic Initiatives and Foundation Exec Director Stillman College Randy Phillips Executive Director of Indian Rivers Behavioral Health Center DCH CCHS Health care Disparities Committee Sammy Watson Director of Community Relations DCH Health System Dr Bob McKinney Director of UMC Department of Social Services Billy Kirkpatrick PhD CEO Five Horizons Health Services and Staff Anne Halli MD Assistant Residency Director Valerie Alford Program Director DCH North Harbor Pavilion Jane Weida MD Chair of Family Internal and Rural Medicine and Director of Clinical Affairs 7

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OBTAINING PUBLIC INPUT According to the regulations in Section 501 r 3 of the Affordable Care Act DCH Regional Medical Center and Northport Medical Center must obtain input from three primary sources within the community 1 experts in public health 2 representatives of the medically underserved minorities and low income populations within the community and 3 written comments received from the most recently conducted CHNA Issues of health that were identified by the Stakeholder group and national and state data included Poor health outcomes and health behaviors Obesity Diabetes Cardiovascular disease The most recent CHNA was uploaded to the DCH Health System website upon completion in 2019 To date no comments have been received For the 2022 CHNA input was received by the required sources as well as from pertinent stakeholders in the community to include government officials law enforcement first responders educators religious leaders other service and not forprofit agencies and active community leaders Hypertension Access to Care Lack of dental mental and primary care professionals Poverty Uninsured Lack of Resources especially in the rural areas Following approval of this report by the DCH Health System s governing board this report will be made widely available through the DCH Health System website for public viewing and comments The following is a review of the 2019 CHNA and the current input received during this process 1 2019 2021 CHNA REVIEW The 2019 CHNA identified health needs in the community stated the prioritized needs determined by the leadership of the DCH Health System and listed action plans to address those needs The Board of Directors approved the CHNA The findings and conclusions are summarized as follows The Community was defined as the 7 county area served by DCH Regional Medical Center and Northport Medical Center The counties include Tuscaloosa Bibb Hale Green Fayette Lamar and Pickens Sexually transmitted diseases Gun violence Transportation Lack of job training Unaffordable childcare Poor Nutrition Opioid crisis Mental health The following three identified health needs were considered priorities Action plans to address those needs were also developed 1 Access to Care Actions to achieve included Free breast screenings to women with no insurance with a focus on the Hispanic population 9

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DCH Health System was one of the first DCH employees contributed more than facilities in Alabama to offer drive up testing for COVID 19 Tests were offered at no charge 100 000 00 to the United Way and its member agencies These agencies provide services to the low income and underserved in the area DCH constructed a stable metal building providing more shelter on campus for COVID 19 testing and vaccination The DCH Diabetes and Nutrition Education Center provided free diabetic testing supplies and education to DCH employees and family members A full time physician recruiter was hired resulting in nine new hires to provide services in the local community DCH partnered with the University of Alabama to support the Tuscaloosa SAFE Sexual Assault Forensic Examiner Center The center provides sexual assault survivors assistance in an appropriate setting away from the DCH campus 3 Mental Health Substance Abuse Actions to achieve included North Harbor Pavilion at Northport Medical Center added a new psychiatrist to its staff North Harbor partnered with Maude Whatley Health Center to provide off site services A van was used to visit the Community Soup Bowl Office of Pardons and Parole and other public locations A CRNP and additional staff participated and visited various tent sites where the homeless resided This service had to be halted due to COVID 19 2 Risk Factors resulting in leading causes of death Actions to achieve included The Lewis and Faye Manderson Cancer Center at DCH sponsored the survivor tent at the American Cancer Society s Relay for Life in April 2021 North Harbor supported and participated in The Cancer Center also sponsored a colon the Tuscaloosa Mental Health Alliance North Harbor s community education manager serves as the group s president cancer health fair in March In 2020 the Cancer Center sponsored Don t Fry Day a skin cancer education event The community education manager at North Harbor was trained in Talks Save Lives Program which was a suicide prevention program for K 12 students Unfortunately this was also halted due to COVID 19 The employees of the DCH Health System continue to contribute to the DCH Foundation through the We Give campaign The funds are distributed to various DCH departments in the form of grants used for community outreach activities Thousands of dollars have been used for patient assistance including home medical equipment medications prostheses transportation diabetic education and testing supplies food and more A registered nurse at North Harbor has been certified in crisis negotiation by the Federal Bureau of Investigation North Harbor and local law enforcement have collaborated with cross training in mental health and crisis intervention to better serve the community when such services are needed The Trauma Services Department provided Stop the Bleed Kits for area schools DCH employees participated in the American Heart Association fundraising efforts exceeding the goal set by Chief Operating Officer Paul Betz by raising more than 30 000 In 2023 the DCH CEO will chair the fundraising campaign 10 The following action plans implemented in prior CHNAs are ongoing Continue to make education material available in the community in the areas of diabetes obesity mental health substance abuse and

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suicide prevention through health fairs school programs community forums and sponsorship of local events Continue employee contributions to the DCH Foundation which provides grants that impact the community Collaborate with other local agencies and providers to increase access to care Use social media and advertising campaigns to educate the public on various health related issues The DCH Health System maintains a smokefree environment on all its properties Continue the DCH Golden Years Program an education program for those over 50 focusing on healthy eating cardiovascular education fall prevention and the Medicare prescription drug program Continue employee contribution support of the United Way Continue outreach to West Alabama residents for patients needing mental health services Continue participation in the Tuscaloosa Mental Health Alliance Continue recruitment of physicians of multiple disciplines to address access to care for the entire community 2 STAKEHOLDER INPUT As noted previously in this report multiple meetings were held with multiple stakeholders over several weeks The following are notes from the meetings Billy Kirkpatrick PhD CEO of Five Horizons Health Services and staff DCH Health System staff member Sammy Watson and facilitator Stephanie Craft met with Dr Billy Kirkpatrick CEO Tyler Keenum nurse practitioner and Clinical Director and Derrick Steverson Director of Community Partnerships of Five Horizons Health Services Five Horizons Health Services FHHS is a non profit organization formerly known as West Alabama AIDS Outreach serving 10 counties in West alabama West Alabama AIDS Outreach was founded in 1988 to provide HIV related outreach and prevention services Since then the agency has grown to include a variety of services for people in the community needing general and specialized care and is now called Five Horizons Health Services Services provided include HIV case management and counseling housing assistance HIV AIDS prevention education and free HIV testing They also provide the SISTA program a program developed by the CDC aimed at preventing HIV in African American women because this group contracts HIV more quickly than any other demographic group They are also in a partnership with The University of Alabama to increase COVID 19 vaccinations in the African American community Dr Kirkpatrick and his staff note that HIV was widespread in West Alabama especially in communities with high poverty rates The group opined that because of the stigma associated with HIV or the fear of testing for the disease many individuals refrain from seeking preventive care For this reason many patients use the emergency department for treatment They also noted that transportation was an obstacle for many individuals in the rural counties in West Alabama The group s goal is to eliminate the barriers to care for those affected by HIV and other sexually transmitted diseases along with providing more preventive care for those who may be at risk of getting these diseases The group suggested a partnership with the DCH labs to get results in a timelier manner eliminating one barrier It was also suggested that DCH inform appropriate patients upon discharge from the emergency room of the services provided by FHHS especially those who might be victims of sexual assault Dr Kirkpatrick and his staff also suggested a Lunch and Learn to educate DCH staff on the programs and services provided through FHHS Finally a mobile clinic option was offered as a possible collaboration between DCH and FHHS 11

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Valerie Alford Program Director of North Harbor Pavilion and Jennifer Singleton Community Education Manager at North Harbor Pavilion their mental disorders Discussions are taking place with the leadership of the DCH Health System to consider adding psychiatric beds to North Harbor This process will take time as a Certificate of Need will be required however there is abundant community support for this project There are also plans to provide a shot clinic at North Harbor This would allow patients to come to the clinic and get anti psychotic shots when needed North Harbor intended to have a bus that would rotate to different locations where the homeless lived to administer medications but that plan also was halted due to COVID 19 Staff shortages have also prohibited implementation of this program Mr Watson and Ms Craft met with Valerie Alford and Jennifer Singleton of North Harbor Pavilion North Harbor Pavilion is a mental health treatment facility for adults and senior adults located at Northport Medical Center Patients at North Harbor receive inpatient nursing care group therapy mental health education and a discharge plan designed to improve their quality of life Patients work with an interdisciplinary highly skilled and compassionate team led by board certified psychiatrists Ms Alford and Ms Singleton reviewed the health needs that were discussed in 2019 and agreed that a few of the issues remain including adolescent suicide a lack of inpatient beds and mental health staff Another initiative of North Harbor is to implement the Screening Brief Intervention and Referral to Treatment program SBIRT The staff at North Harbor has been trained and the local police department has been notified of North Harbor s readiness They are waiting on referrals The SBIRT program is a comprehensive integrated public health approach for early identification and intervention with patients whose patterns of alcohol and or drug use put their health at risk This program is designed to address the needs of individuals in the community who have been admitted on multiple occasions for drug or alcohol abuse with the hope of early intervention to mitigate admissions to North Harbor Previously there was a major need for a psychiatrist however recruiting efforts have been successful and another psychiatrist has been added Better access to medications for patients was also an issue but North Harbor now has its own pharmacist who makes rounds with the physicians allowing for greater access to needed medications in a timely manner The biggest issue facing North Harbor is the lack of inpatient beds both for adults and certainly for adolescents Since the COVID 19 pandemic began North Harbor has seen an increase in depression anxiety and suicide in children under 18 With the onset of COVID 19 schools were shut down and students were isolated Some had no access to the internet cutting out their ability to communicate with friends through social media COVID 19 also prohibited Valerie and Jennifer from going into the schools to implement the Talks Saves Lives program which is designed to prevent suicide in adolescents The plan is to begin implementation of this program in the near future It has also been noted on prior CHNAs that the closing of most of the beds at Bryce Hospital has left many patients in the community with no place to go Many of those patients are homeless and are not receiving the necessary medications for 12 Finally The Alabama Department of Mental Health received funding to start two additional crisis diversion centers in Alabama with one being located in Tuscaloosa North Harbor staff will play a role in this center The center will be a designated place for law enforcement first responders and others to take an individual that is in a mental health or substance abuse crisis It is a short term stay where an individual can receive stabilization evaluation and psychiatric services It is the hope that this Crisis Diversion Center will reduce inappropriate arrests and visits to the emergency department

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The goal is to continue to market the program to physicians for referrals to offer the program to all DCH employees and to work with other organizations in the area such as Shelton State Community College to educate students on obesity proper nutrition and exercise to prevent the onset of diabetes It is the desire of the staff to team with an endocrinologist in the same building where the education program is currently held This would allow for an interdisciplinary approach for prevention and treatment of diabetes David Anderson Director Cindy Huggins Dietitian Marsha Fowler RN DCH Diabetes Education Center Mr Watson and Ms Craft met with David Anderson Cindy Huggins and Marsha Fowler certified diabetes care and education specialists with the DCH Diabetes Education Center It was noted that throughout the seven county community diabetes is the sixth leading cause of death The issues of health closely related to diabetes include obesity physical inactivity and cardiovascular disease According to national data Alabama has the third fastest projected increase in diabetes and it is projected that Alabama s diabetes rate will increase by 38 percent over the next 10 years through 2030 Most of the areas where this rate increase will occur is in areas of low education and high obesity rates Mr Anderson Ms Huggins and Ms Fowler stated that there is a great need for additional education in the public regarding diabetes As stated before COVID 19 hampered the ability of the staff to get out and market heavily to physicians and in public health fairs Restrictions are being lifted and staff now has the ability to amplify marketing efforts COVID 19 also limited the number of people who could participate in an education class Classes are now resuming at pre COVID size This department started a Living Well with Diabetes Employee Program and it has been very successful however it is only available to employees on the DCH Health System insurance plan The Center wants to include all DCH employees on this plan to make the DCH workplace more aware and to improve the overall health of the employees Another issue reported is that although doctors are referring patients to the program the patient does not always show up Transportation is a barrier for some The staff noted that education is critical in management of diabetes DCH internal statistics showed that graduates who completed the education program were not re admitted to the hospital for any reason proving great success for the program 14 It should also be noted that The US Department of Health and Human Resources Healthy People 2030 continues to include the goal of reducing the burden of diabetes and improving the quality of life for people who have or are at risk for developing diabetes Many of the program initiatives of the DCH Diabetes Education Center mirror the objectives set forth in Healthy People 2030 Karen Thompson Jackson PhD CEO of Temporary Emergency Services of Tuscaloosa and member of Tuscaloosa City School Board Temporary Emergency Services TES is a not forprofit organization that was started in 1945 by local churches in the community to assist individuals and families in crisis situations enabling them to survive the immediate crisis they are encountering Ms Thompson Jackson s organization serves the low income medically underserved and uninsured in the community The organization is funded by the United Way local businesses churches and individuals Services include but are not limited to provision of clothing food medications transportation baby items and assistance with utilities and rent TES has also developed community gardens allowing clients to grow their own fruits and vegetables which provides an opportunity for clients to save money on food and learn about healthy meals and proper diets Ms Thompson Jackson expressed that many of the TES clients are very low income and some are homeless There is a constant need for food clothing

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and medications She noted that their homeless clients do not have a place to shower or a place to wash their clothes Recently the organization received a grant that has provided two shower stalls and washer dryer units at the Tuscaloosa thrift store location Ms ThompsonJackson also said that many clients have mental health issues and while assistance is provided for the immediate need there is a secondary need that is not being met Clients need additional information to take with them once their initial need has been met and they often need case management to help prevent the need from arising again Ms Thompson Jackson said it would be very beneficial for DCH Regional Medical Center and Northport Medical Center to provide volunteers from human resources finance and media to assist TES with applying for additional grants and renewing existing grants She also said it would be a great service for if both hospitals could be a resource for her clients from a case management and social work perspective after regular business hours especially on the weekends Volunteers are always needed and she suggested sending an email out to all DCH employees to enlist participation TES currently partners with many organizations in the area including several University of Alabama sororities and students in the public relations program to provide efficient and effective programs to clients Rob Robertson Probate Judge of Tuscaloosa County and Chairman of the Tuscaloosa County Commission Judge Robertson confirmed that there is a big mental health crisis in Tuscaloosa and surrounding counties He said there are not enough mental health beds available in the area and because of that many patients suffering from a mental health crisis end up in the emergency department or jail which is often inappropriate and ineffective He also stated that juvenile mental health services are needed He explained that the socio economic status of many families in the area creates an unhealthy environment leading to bad behaviors in these adolescents Factors related to COVID 19 including school shutdowns also contributed to an increase in crime substance abuse depression and anxiety for many young people As a result more and more adolescents are needing mental health services and are unable to get them Brewer Porch a school serving children and teenagers with psychiatric behavioral and emotional problems operated by the University of Alabama has inpatient and 14 outpatient treatment programs to address the many needs identified in the area however the school serves children from all over Alabama and there are not enough beds available He also noted that there is a large waiting list of 52 54 individuals that have been committed through the court system to Bryce Hospital but there are no available beds North Harbor Pavilion at Northport Medical Center is also full and has no available beds most of the time In addition Judge Robertson stated that Tuscaloosa County is served by one ambulance company In addition the Tuscaloosa County governing body has purchased one ambulance and plans to buy another There are many people who use 911 for general health care This ties up ambulances for minor health problems and as such they are unavailable when a true emergency occurs He also stated that long wait times at the hospital emergency departments keeps ambulances out of service for long periods of time One final issue he identified was the mass discharge from the hospitals at the same time during the afternoon He said there are not enough ambulances to cover all the discharged patients He recommended that discharges at the hospital be staggered to better accommodate patient transfers 15

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Mark Sullivan Executive Vice President of Bryant Bank Mr Sullivan is a member of the Tuscaloosa Chamber of Commerce and is actively involved in the business community in Tuscaloosa County He opined that the community perception of DCH Regional Medical Center needs improvement While he is very supportive he believes the DCH Health System should be more offensive and proactive in marketing efforts designed to educate and promote the services provided by the hospitals He said this was especially true as it relates to cardiac care and oncology services In particular he noted that many friends were going to larger hospitals in other cities for those services and to protect the viability of the hospitals those patients needed to stay in Tuscaloosa He said the DCH Health System has been very successful in recruiting new physicians and that information should be more effectively communicated to the public He acknowledged the nursing shortage and the costliness of traveling nurses suggesting that perhaps the DCH Health System should provide a more robust offer benefit package Linda Forte PhD and Retired Nurse Educator at Stillman College in Tuscaloosa Alabama Dr Forte is the former Director of the Nursing Program at Stillman College She is a native of Pickens County serves on multiple boards in West Alabama and has extensive health care knowledge and experience Currently Dr Forte is a board member of the Tombigbee Resource Council and Development Office which promotes conservation and the use of natural resources to improve quality of life for the communities served The Council serves an 8 county area including Bibb Tuscaloosa Hale Green Sumter Pickens Lamar and Fayette The council has received multiple grants which will fund multiple projects throughout the service area in 2022 to improve education safety health care and technology Dr Forte stated that through her experience in West Alabama she continues to see access to care as a major barrier 16 in the rural areas Several hospitals in rural areas have closed leaving many individuals and families in these rural areas without access to basic primary care While some towns in West Alabama have primary care clinics others do not and because transportation is often a barrier many do not receive any health care at all resulting in high risk behaviors and poor health outcomes which is supported by health data submitted with this report Dr Forte also noted that mental health is an identified health need throughout West Alabama in seniors and adolescents Pickens County Hospital closed its geriatric psychiatric unit and as a result there are very few geriatric psychiatric services in West Alabama She also said that as a result of school shutdowns during the COVID 19 pandemic there was an acceleration of mental health issues among children Many children in the area did not have their food needs met because they could not attend school She also said many families in rural West Alabama did not have internet access and students were unable to complete their classroom study material resulting in failing grades Dr Forte said she hopes the DCH Health System will consider additional inpatient psychiatric beds at North Harbor Pavilion continue the partnership with Maude Whatley to visit homeless tent cities in Tuscaloosa and continue to contribute funding to the local nonprofit organizations in West Alabama that provide essential services to the rural communities in West Alabama Cynthia Burton CEO of Community Service Program and the Chairman of Maude Whatley Board of Directors David Gay CEO of Whatley Health Services DCH Health System Board member Pastor of Beulah Baptist Church and former Director of Bryce Hospital and Taylor Hardin Mental Health Facility As required by the Affordable Care Act DCH Regional Medical Center and Northport Medical Center must take into account input from those individuals or groups representing the medically

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underserved low income and minority populations The organizations represented by Ms Burton and Mr Gay provide a comprehensive array of services to the underserved uninsured and minority populations throughout West Alabama DCH Regional Medical Center and Northport Medical Center have worked with each of these organizations for many years to ensure their clients receive high quality appropriate and timely care Community Service Programs of West Alabama is a private nonprofit community action agency that provides education services housing services and support services to include meal delivery elderly assistance energy assistance and case management to low income and vulnerable populations in a 10 county area in West Alabama The goal of this agency is to create self sufficiency and better quality of life for those in the communities served Whatley Health Services is a private nonprofit community health center that provides primary health care and dental care in multiple locations throughout West Alabama Medical services include internal family pediatric and adolescent care mental health care Women s Infants Children WIC chiropractic care HIV AIDS care prenatal care dental care ENT services pharmacy services and laboratory services Mr Gay the CEO of Whatley Health Services has more than 30 years of experience in the mental health arena Through his church ministry he has identified multiple issues of health stating that although the DCH Health System and its hospitals have worked tirelessly to address the identified issues they are still prevalent in the community Issues of health identified by him included the lack of community resources transportation ramifications from the COVID 19 pandemic affordable housing in the Tuscaloosa area wait times in the emergency room domestic violence the homeless and the language barriers faced by the ever growing Hispanic population Mr Gay pointed out that public transportation system is terrible and that it is not a priority for the city The buses stop running at 4 p m and do not run on the weekends More money is needed to expand bus operations during the week and to provide some service over the weekend Mr Gay said that so many people need basic health care services that Whatley Health Services has extended its hours until later at night and on the weekends to accommodate individuals and families needing services He also stated that it is too early to tell how the COVID pandemic affected adolescents He said there has been an increase in suicide among children and many have fallen behind in school studies because they did not have the resources to complete schoolwork He also said many families did not seek out health care during the pandemic because they were told to stay home and this has affected the overall health of these families Mr Gay also said there is not adequate affordable housing for low income families in Tuscaloosa in part due to the lack of land available for development This has resulted in an increase in homelessness in the area Mr Gay s organization has seen a big increase in the Hispanic population needing health care services Language issues have been a problem so Whatley Health Services has hired a bilingual employee and offers forms in English and Spanish to improve communication and relationships Ms Burton stated that there are minimal primary care services in the rural areas and what is available is only open during certain hours of the day and very rarely on the weekend For this reason patients are using the emergency rooms at both hospitals for basic health care services This is causing extremely long wait times in the emergency department Ms Burton expressed that the high rate of inflation is causing major health issues for low income and uninsured families People are being forced to choose between taking medications and eating so there is a great deal of food insecurity for many in these vulnerable populations The cost of childcare is prohibitive for some and for this reason many mothers and fathers are unable to work because they have no means to pay for childcare She also stated that socialization in the elderly population is a major mental health issue 17

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Many of the older houses that low income families live in are not accessible to those with walkers or wheelchairs so these people become prisoners in their own homes resulting in depression and anxiety Ms Burton agreed with Mr Gay that for the low income and minority populations there is a great lack of resources which she said contributes to poverty They also agreed that domestic violence increased exponentially during the COVID epidemic People lost their jobs were locked in their homes had little to no income and all this created extreme stress which often resulted in domestic violence in the home Resources need to be available to address this problem Ms Burton and Mr Gay are actively working to increase education and awareness of their services in hopes of decreasing visits to the emergency room It is their desire that DCH Regional Medical Center and Northport Medical Center staff also work to educate discharged patients on the services provided by these essential organizations Lynn Armour Executive Director of the Good Samaritan Clinic in Northport Alabama Ms Armour is the Executive Director of the Good Samaritan Clinic a nonprofit free clinic which opened in 1999 The clinic is staffed by volunteer physicians pharmacists dentists nurses counselors and others who provide primary health and dental health care to more than 350 uninsured and underinsured adults aged 19 64 All patients must have a household income at or below 200 percent of the federal poverty level and must live in Tuscaloosa Greene Pickens Hale Bibb Fayette or Sumter counties The Good Samaritan Clinic is the only free clinic in the seven county area The clinic operates on funding provided by churches individuals United Way corporate donors and fundraising Ms Armour stated that transportation is one of the biggest issues facing many of these patients While many of the local churches provide 10 gas cards many of the patients are unaware that the cards are available Ms Armour also stated that many patients are unfamiliar with the services the clinic provides and as a result go to the emergency room at DCH Regional Medical Center or Northport Medical Center for basic primary health care or to get refills on medications to treat their chronic conditions She suggested that it would be helpful if both hospitals could distribute postcards for example to uninsured patients with information about the clinic Ms Armour explained that all patients must meet certain criteria in order to qualify for treatment and it is a humbling process By reaching some of the patients that present at the emergency room Ms Armour feels it would improve access for many who will not seek care at all She suggested meeting with case managers and emergency department nurses of both hospitals and EMTs to improve recognition of the clinic and their services She also expressed the need for more support in the rural areas to distribute gas cards in the community enabling patients to get to the clinic The Good Samaritan Clinic partners with organizations in the area to assist with clinical care and other important services The University of Alabama s College of Community Health Sciences sends residents who volunteer their time to help with patient care The Clinic also collaborates with Jeremiah s Garden which is a community garden providing fresh healthy food to those in need Dr Richard Friend MD Dean of the University of Alabama College of Community Health Sciences The College of Community Health Sciences was established at The University of Alabama in 1972 to solve the critical need for health care in rural Alabama It was also designated as a regional campus of The University of Alabama at Birmingham to provide clinical training to medical students More than 900 medical students have been trained in family medicine internal medicine pediatrics obstetrics and gynecology psychiatry neurology and general surgery The medical clinic provides health care from five locations in West Alabama and is the largest community practice in West Alabama 19

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with more than 150 000 patient visits annually In addition the College operates the University of Alabama Student Health Center and Pharmacy and the Brewer Porch Children s Center The Institute for Rural Health Research which conducts research focused on improving the quality of life for citizens in Alabama s rural counties is also located at the College Dr Friend stated that the College has one of the largest family medicine residencies in the country and it is his hope to continue to grow this residency program Dr Friend noted that patient satisfaction surveys completed by patients upon discharge showed dissatisfaction with the past hospitalist group that contracted with DCH Health System As a result the System and board chose to make a change Through the request for proposal RFP process they decided to enter into an agreement with Capstone Health Services Foundation an affiliate of the University Medical Center and IN Compass Health a physician staffing and management company Through this agreement a new hospitalist group began providing services at DCH Regional Medical Center and Northport Medical Center in the fall of 2021 Since this partnership began almost a year ago patient satisfaction scores have improved The LEAN Project which was a pilot program started in one wing of the hospital took a team approach to treatment The team included a doctor nurse respiratory therapist and case manager This was well received by most patients Dr Friend expressed the importance of the sustainability of the hospital and in his opinion providing excellent care was the key to keeping patients at the local hospitals instead of losing them to hospitals in bigger metropolitan areas He expressed concerns that employing physicians had been extremely cost prohibitive due to COVID 19 and he was uncertain as to when that trend would change He compared it to employing traveling nurses and the costs associated with that process Finally Dr Friend expressed the need for a psychiatry residency program to recruit more mental health professionals to the area He said 20 there was an immediate need for more mental health services and physicians to provide care for adolescents in West Alabama Bobby Herndon Mayor of the city of Northport Alabama Mr Herndon serves as the Mayor of Northport and as a governmental leader understands many of the health issues facing the citizens of his community especially as it relates to law enforcement the fire department and EMT providers Mr Herndon expressed concern about the wait times in the emergency department of the hospital He said ambulance drivers and fire medics were having to sit and wait for hours to get patients into the hospital potentially taking valuable time away from other emergencies He recognized the staff shortage crisis and said Northport Medical Center had created a discharge lounge so that it would make more space available but he sees the need for faster admit and discharge policies Mr Herndon also expressed the need for more discipline in the home During the COVID 19 pandemic children and teenagers were forced to stay at home and this created an increase in gang activity and ultimately gun violence and drug abuse He said the violence in Tuscaloosa County is growing and many people are moving out of the city to safer locations in more rural areas of the county Chris Cox PhD Interim President and Jonathan Koh PhD Dean of Workforce and Economic Development Shelton State Community College Dr Cox and Dr Koh are excellent representatives from the education arena Shelton State Community College is a two year college located in Tuscaloosa and is one of the largest community colleges in the state More than 7 000 students are enrolled in some type of coursework and students of varying ages and ethnicities attend the school Dr Cox and Dr Koh both agreed that there was a great need in the community for additional nurses Although Shelton State has associate nursing practical nursing and nursing assistant home health aide programs

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they plan to update and grow the program even more A suggestion was made to partner with The University of Alabama and the DCH Health System to expand the program In addition both men agreed that diabetes obesity and overall nutritional health was an issue for many of the students at the school It was suggested that Shelton State reach out to the DCH Diabetes and Nutrition Education Center to collaborate in health fairs the school s annual Diabetes Walk and to provide education to students in the classroom Finally Dr Cox and Dr Koh opined that mental health was a major issue affecting many of their students Dr Koh and his staff conducted a mental health survey in 2021 during the COVID 19 pandemic which showed that many of the students who responded had mental health issues including depression anxiety stress and suicidal tendencies Many of the students come from high poverty areas and are single parents which compounds those problems It is the hope of Dr Cox and Dr Koh that the Alabama Mental Health Department s crisis diversion center will become a safe haven for their students as opposed to arrests or treatment in the emergency room when a crisis occurs Rasheda Workman Vice President for Strategic Initiatives Stillman College Executive Director of the Stillman Foundation In addition to her duties as VP for Strategic Initiatives and Executive Director of the Stillman Foundation Ms Workman is also the liaison between the Board of Directors and the College Her office is instrumental in applying for and receiving federal grant funds to assist communities in West Alabama s Black Belt to build health care networks Her office oversees career services governmental relations corporate affairs workforce development community relations and the school s foundation She is also a member of Blackbelt Roots which is a grassroots coalition whose purpose is to raise awareness of the social economic health challenges and best practices in 12 counties in West Alabama Ms Workman said that the most pressing issues of health she identified were access to care and the comorbidities facing many in the Black Belt She stated that individuals and families in West Alabama especially in the rural areas are simply unaware of many of the resources available to them and as such lead unhealthy lifestyles and do not seek preventive care She also noted that recruiting physicians is very difficult in rural communities therefore specialty care is unavailable Ms Workman also stated that transportation is a major issue of health for many in West Alabama resulting in poor health outcomes that lead to the major causes of death in all counties Randy Phillips Executive Director of Indian Rivers Behavioral Health Center Indian Rivers Behavioral Health is a nonprofit organization established more than 50 years ago that provides adult child and family services to diagnose and treat mental illness substance abuse and intellectual disabilities Indian Rivers serves residents of Bibb Pickens and Tuscaloosa counties In 2020 more than 120 000 services were provided to more than 4 400 individuals Mr Phillips identified mental health in adolescents as a major health issue and suggested the COVID 19 pandemic was a primary contributor to that problem He also said transportation was an issue that prevented access to mental health services To help mitigate this problem Indian Rivers offers the Journey Program which is a collaboration between Indian Rivers and the Tuscaloosa City School system providing therapeutic services to students experiencing emotional and behavioral problems This program provides treatment by therapists to children at school with the intent of improving access reducing the stigma of being treated at a mental health facility and educating students and their families on mental health issues to decrease 21

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the rate of crisis situations He also said the use of telemedicine was very important in creating better access to care especially in rural areas Mr Phillips stated there was a tremendous need for additional inpatient mental health beds in West Alabama He said more than half of the population at Bryce Mental Hospital are committed by the court system as not guilty by reason of insanity He also said there were no available beds at Taylor Hardin Mental Facility creating a massive backlog of patients waiting for a mental health bed Because of the lack of available beds many patients end up in jail or the emergency department when a crisis occurs Tuscaloosa County has been declared a Stepping Up community The Stepping Up Program is a national initiative that creates a collaboration of local community agencies and individuals whose purpose is to develop policies procedures and services to reduce the incidence of mental health events that result in arrests and visits to the hospital emergency departments The intent is to identify those patients needing intensive mental health therapy and to be proactive in making timely referrals for treatment for those patients Mr Phillips said he would like to see a collaborative team created with the leadership of local organizations to conduct a gap analysis to identify what is missing in the community as it relates to services and define the next step to address those gaps The DCH Health System and University of Alabama College of Community Health Services Disparities Committee This committee is comprised of individuals in the DCH Health System and the College of Community Health Services at The University of Alabama whose purpose is to improve the physical and mental health of residents in West Alabama by achieving health equity in the communities served by eliminating racial cultural sexual and gender based disparities Five members of the committee spoke to issues of health in the communities 22 Dr Anne Halli identified access to care as an issue She noted that transportation is unavailable for many and prohibits vital access to medical services She also stated that during the pandemic residents of the community stayed home and many did not have access to broadband creating an even greater need for improved access Dr Jane Weida identified transportation as a major barrier to health services She also said that due to the rising cost of food many patients could not afford healthy food She stated that in the town of Carrollton located in Pickens County Alabama there is no grocery store Dr Weida also said that many of the uninsured in West Alabama could not afford medications or basic primary care which leads to multiple health issues including diabetes obesity and high blood pressure Dr Bob McKinney noted that there was a lack of services for African American women which resulted in a higher than normal maternal and infant death rates in the community Ms Kirsten Henry stated that due to the lack of K 12 educational resources in rural areas this leads to increased levels of unemployment Illiteracy is also a factor as it presents significant challenges to acquiring the types of jobs that will improve access to care increase quality of life and greater access to enhanced educational opportunities She also stated that food insecurity was a major concern in the rural areas Finally Dr Wendi Parminter reported that many patients did not have access to resources and because of that did not seek follow up care upon discharge from the hospitals She suggested this resulted in inadequate care for cardiac patients as well as other patients with multiple comorbidities She stated that the goal of both hospitals is to improve patient education before they are discharged from the hospitals Tuscaloosa Fire and Rescue Five members of the Tuscaloosa Fire and Rescue team met with facilitator Stephanie Craft and DCH Health System Director of Community Relations Sammy Watson Tuscaloosa Fire and Rescue has 11 stations and more than 250 firefighters providing

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fire prevention firefighting emergency medical care water rescue technical rescue hazardous materials mitigation code enforcement disaster response public education and community service Chris Williamson Deputy Chief of Operations Chris Holloway EMS Chief and Brianna Jones Lauren Ramsey and Emma Simms also with the EMS prevention program offered their opinions on the major issues of health facing those in the Tuscaloosa community Mr Holloway began by addressing the numerous 911 calls received by Tuscaloosa Fire and Rescue He said that most of those calls were non emergent and occurred because individuals did not have transportation or because they did not have adequate follow up from past trips to the emergency room These people are considered frequent flyers who consume valuable resources and time often impeding responses to true emergencies for the Fire and Rescue team Mr Holloway and his team suggested the 911 calls are not often medical emergencies but instead result from social needs He suggested a collaborative effort between Tuscaloosa Fire and Rescue and the DCH Regional Medical Center and Northport Medical Center social workers to identify the hot spotters visit them regularly to assess the situation and decrease the 911 calls The team also identified mental health as a major issue in the area They stated that 80 percent of the 30 50 frequent flyers they respond to have a mental health issue Loneliness is the predominant reason Mr Holloway suggested establishing a support group for these people similar to what the local church organizations offer to reduce the need for these individuals to make 911 calls The team also said chronic heart failure is another major issue of health The team suggested DCH Foundation provide approximately 50 free echocardiograms each year which would help identify those at risk and possibly prevent a major cardiovascular event The EMS staff also stated the need for improved education for community residents They plan to continue to use social media for this and hope to start a You Tube channel in the near future with weekly education segments Col Lee Busby Member of the Tuscaloosa City Council Retired Marine Infantry Officer Col Busby discussed the issues that are presented to the City Council at their meetings He said there were concerns among residents in the community that paying customers those with insurance went to other hospitals outside of the Tuscaloosa area for some services and that only the non paying customers were going to the DCH Health System hospitals He said the City Council wants to address this issue He also said the Healthgrades rating system which rates the hospitals on their services is alarming to members of the Council He wants to resume luncheons between the Council and the leadership of the DCH Health System to keep the Council informed and to present a long term vision for the hospitals He feels this would eliminate anxiety among Council members and would be beneficial as it relates to communication between the Council and the DCH Health System Col Busby also stated that substance abuse gun violence and crime throughout the community were major issues of health Beth Goodall RN Director of Infectious Diseases for the DCH Health System Ms Goodall s department is responsible for the public reporting of all infections throughout the DCH Health System The infectious disease department was responsible for COVID 19 testing and vaccinations throughout the pandemic She said that the drive through testing provided by DCH Regional Medical Center was extremely efficient and was positively received throughout the community She stated also that the department administered more than 70 000 vaccines during the COVID pandemic Ms Goodall cited several issues of health facing the community including nursing staff shortages long wait times in the emergency departments of both hospitals and the need for better community relations She suggested Shelton State Community College expand their existing nursing program and bring back LPNs as part of the nursing team in the hospital settings In addition she said that the emergency departments are landlocked as they 25

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exist now and cannot be expanded To compensate for that she suggested the DCH Health System consider a free standing emergency department to add additional emergency coverage She also said that since wait times were long a patient advocate positioned in the emergency rooms would be beneficial to improve communication and coordination for patients Ashley Adcox The Aging Services Director of the Area Agency on Aging of West Alabama The West Alabama Area Agency on Aging has provided services to older persons and their families and the disabled for more than 40 years The Agency serves more than 830 clients in Bibb Fayette Greene Hale Lamar Pickens and Tuscaloosa Counties with their programs and their resources are designed to assist the elderly in maintaining their independence safely and efficiently for as long as possible Qualifying adults can receive advice on health insurance legal counseling home delivered meals help with household chores discounted prescription medications placement in part time jobs health promotion classes long term care services housing and many other services Ms Adcox expressed concerns that there was a lack of dental and vision insurance coverage for many older adults and the Agency program does not provide this benefit She also said transportation was a major issue of health and prevented many of the elderly from receiving the medical care they need Shanna McIntosh VitAL Director at the University of Alabama School of Social Work Ms McIntosh holds a master s degree in counseling and psychology and has more than 10 years experience as a substance use treatment director As VitAL Director she oversees several grants that fund the VitAL program She is an advisor to the board for the Parent Resource Institute of Drug Education of Tuscaloosa and the Tuscaloosa Mental Health Alliance and is the co founder of the West 26 Alabama Recover Coalition The VitAL program is a research implementation and training initiative that focuses on behavioral projects that focus on treatment prevention and recovery of substance abuse with the goal of creating greater access to appropriate and effective care for those affected by mental health The program is a strategic plan to work within local communities and it touches all 67 counties in Alabama Ms McIntosh said that in many counties in Alabama health care is fractured which is a problem for those needing more integrated care Ms McIntosh said that care should include primary care emotional care and behavioral care creating a more seamless system to address the whole of an individual to improve outcomes Ms McIntosh also suggested DCH Regional Medical Center reconsider implementation of the SBIRT Program SBIRT is screening brief intervention and referral to treatment for mental health patients She believes this should be the standard of care for treating mental health in Alabama and would be most beneficial at DCH Regional Medical Center since Northport Medical Center has North Harbor Pavilion where staff is currently trained and has begun implementation of the SBIRT treatment plan This would allow for a universal screening approach more appropriate referrals more efficiency in the emergency department and ultimately better outcomes for patients Ms McIntosh is currently working with the State of Alabama Medicaid program to make changes to the current billing system for pregnant women to allow for a more integrated care system Ms McIntosh suggested that Tuscaloosa is the mental health mecca and there is a constant influx of individuals needing mental health care She suggested a robust boots on the ground group to educate everyone in the community on the SBIRT program She also suggested collaboration with first responders on training of this program And finally she suggested additional participation from DCH Health System in prevention and treatment of patients suffering from opioid abuse

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Cynthia Lee Almond Alabama House of Representatives member serving District 63 Ms Almond a Tuscaloosa native is an attorney and has been active in the Tuscaloosa community for many years She served on the Tuscaloosa City Council for 16 years and was the Council s president during her last term She now represents the Tuscaloosa area as a member of the Alabama Legislature representing House District 63 She has also served on many local boards in the area including the West Alabama Regional Commission First National Bank of Central Alabama the Capstone Health Services Foundation and the Tuscaloosa Tourism and Sport Commission Ms Almond opined that health education especially with children is much needed in the community She noted poor food choices and lack of exercise was compounding the obesity diabetes and overall poor health issues facing citizens in the community Ms Almond also stated the nursing staff shortage as a major concern She suggested the need for growing the nursing pool and creating a more stable workforce to avoid the high cost of hiring traveling nurses to fill the gap Ms Almond also expressed a concern over access to care facing many in the community especially in the rural areas She said the continued use of telemedicine was crucial for greater access Since enhanced broadband access legislation was passed in the most recent legislative session she sees greater availability to internet access for many in the rural areas and as such telemedicine may become a more common and accepted method of providing care Finally Ms Almond suggested the need for the hospital to prepare for the health care challenges certain to come in the near future She acknowledged it is a great responsibility for the hospitals to serve their community while building a successful business model and also noted that managing community perceptions created through social media and addressing community expectations is difficult Ms Almond appreciates the relationship she has enjoyed over the years with DCH Health System the Board of Directors and Administration and is confident the System will continue to provide life saving services to citizens in the communities served by DCH Regional Medical Center and Northport Medical Center 3 RELEVANT HEALTH CARE DATA Additional data relevant to the various issues of health can be found in Appendix A B and C All data was obtained from relevant sources including the Alabama Department of Public Health the Robert Wood Johnson Foundation County Rankings and Roadmaps the US Department of Health and Human Services Healthy People 2030 the Centers for Disease Control the American Diabetes Association and others 27

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PRIORITIZED NEEDS AND ACTION PLANS TO ADDRESS An extensive review of the prior CHNA stakeholder input and other pertinent data was presented to the leadership of DCH Regional Medical Center and Northport Medical Center to prioritize the needs identified through this CHNA process Priorities previously addressed in past assessments were considered as was the potential effectiveness of the action plans and the associated costs The decision was made with the ultimate goal of improving the quality of life and overall health care for individuals and families in the communities served by the hospital The following needs were established as priorities 1 Mental Health Action Plans Explore expanding the inpatient bed capacity specifically for adolescents of North Harbor Pavilion to provide mental health services Grow partnerships with other mental health providers in the area including Maude Whatley Health Center Indian Rivers Behavioral Health and local community mental health centers Continue to provide monetary support for advocacy in the community Implement the FBI s crisis negotiation program at North Harbor Work with Indian Rivers and local first responders to ensure a timely opening of the Crisis Diversion Center to be located in Tuscaloosa County and to provide appropriate staff when needed Resume North Harbor s partnership with Maude Whatley Health Services to provide onsite health services to the Community Soup Bowl the Office of Pardons and Parole homeless tent cities and other public locations in the emergency department for those needing mental health services Resume implementation of the Talks Saves Lives program which speaks to the prevention of suicide in the local school systems Continue support of and participation in the Tuscaloosa Mental Health Alliance to identify gaps in mental health services to provide education and crisis intervention when needed and to improve the quality of life for those with mental health issues Continue to recruit behavioral clinicians as the seven county area is considered to be a mental health professional shortage area Expand telepsychiatry in West Alabama Continue the use of marketing and social media for mental health issues Create a support group using staff from the DCH Health System for Tuscaloosa Fire and Rescue clients to combat loneliness and depression which often results in a 911 call and unnecessary trips to the emergency rooms of the hospitals 2 Access to Care Action Plans Continue and expand free screenings and health fairs in the community Continue partnerships with other local providers including Community Services Programs of West Alabama Maude Whatley Health Services the United Way the Good Samaritan Clinic and others to ensure individuals and families are informed and educated on the services provided by these organizations including meals childcare affordable housing transportation gas cards and other valuable services Implement the SBIRT Program at DCH Regional Medical Center to improve the standard of care 29

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Consider partnership with Five Horizons Health Services to provide a mobile clinic and laboratory services to ensure timely lab results for patients who may have been exposed to sexually transmitted diseases Provide additional resources to those in the community by launching lunch and learn programs for the DCH staff to learn about the services provided by other organizations and agencies in the area Consider expansion of emergency services in the service area of DCH Regional Medical Center and Northport Medical Center through a freestanding emergency department Continue to recruit clinical staff and physicians to the area to ensure adequate clinical coverage for services provided Enlist DCH Health System employees to volunteer to assist other organizations in the area who provide services to those in need Continue marketing campaigns that educate the community on the resources available in the community Continue monetary support to other organizations in the area that provide valuable resources to the community Improve education to patients upon discharge from DCH Regional Medical Center and Northport Medical Center so that they are better prepared on prevention upon their return home possibly avoiding re admissions 3 Contributing Factors that Result in the Leading Causes of Death Action Plans Multiple data provided in this document confirms that obesity hypertension physical inactivity diabetes and other factors contribute to the leading causes of death including heart disease stroke and cancer This has been an ongoing health issue in the communities served by DCH Regional Medical Center and Northport Medical Center since the first CHNA was conducted in 2013 Continue the Lewis and Faye Manderson Cancer Center s sponsorship of local events as well as free health fairs and screenings for cancer 30 Continue the We Give campaign which is employee contributions to DCH Continue DCH Regional Medical Center s participations in sponsorship of local events including the American Heart Association s annual fund drive Continue DCH employee contributions to the United Way of West Alabama s 27 member agencies many of which serve the medically underserved minority and uninsured population Continue the DCH Health System smoke free campus policy Expand the DCH Health System Living Well with Diabetes Employee Program to include all employees of the System and not just those covered under the DCH Health System insurance plan Resume marketing of the DCH Diabetes and Nutrition Education Program in doctor s offices local school systems and through local health fairs as this program was halted during the COVID 19 pandemic Continue marketing campaigns that educate the community on the resources available in the community Implement medical nutrition therapy coverage on the DCH employee health insurance plan Recruit a local endocrinologist to share space in the DCH Diabetes and Nutrition Education Center allowing for an interdisciplinary plan of care for diabetic patients Expand the DCH Diabetes and Nutrition Education Center facility DCH employees volunteer with other organizations providing services to the needy in the form of assistance and grant preparation DCH Regional Medical Center and Northport Medical Center combine resources and staff to provide free mammograms echocardiograms and other screening tools annually to detect certain health issues early hopefully preventing more serious complicated and expensive problems in the future

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DCH Health System partner with the Tuscaloosa Fire and Rescue to provide a social worker and other pertinent staff to improve follow up with their 911 patients and improve communication between both organizations by participating in a monthly meeting to discuss concerns of that population and how to address those concerns Continue marketing campaigns using radio shows and other media to educate the public on various topics including disease management and other issues that affect overall health METHODOLOGY OTHER RECOGNIZED HEALTH CARE NEEDS NOT PRIORITIZED Through this CHNA process multiple issues of health were identified both by the Stakeholder Committee and through national state and local data The decision was made to prioritize mental health access to care and the factors that contribute to the leading causes of death in each county served because these issues have been identified as major issues since this process began in 2013 and continue to affect the overall health of residents in the seven county area served by DCH Regional Medical Center and Northport Medical Center While several additional action plans are introduced in this report and will be considered for implementation leadership of both hospitals determined that existing programs and initiatives should remain in place to more efficiently address those issues that remain constant in the community The ultimate goal of DCH Regional Medical Center and Northport Medical Center is to effectively utilize resources available to meet the health needs of the citizens in its service area while continuing to provide high quality compassionate care for residents in the area regardless of their ability to pay 31

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DOCUMENTING RESULTS PLANS TO MONITOR PROGRESS Following the DCH Health System Board of Directors approval of this report the DCH Health System will make the report available for public viewing and comments on the System s website Every effort will be made to consider and implement the action plans suggested in this report in a timely manner and staff from the DCH Health System will monitor the progress of the plan and document results which will be reported in the next CHNA due in 2025 RESOURCES AVAILABLE TO MEET THE IDENTIFIED HEALTH NEEDS Throughout this report efforts were made to consider the needs of the medically underserved minority and low income populations Other populations were also considered including the growing Hispanic population the homeless population children and those affected by a specific disease While DCH Regional Medical Center and Northport Medical Center provide a wide array of services and treat all patients who present at the hospital for treatment other resources are available to assist the most vulnerable populations Those resources include but are not limited to the following Alabama Medicaid The Alabama Department of Mental Health The Alabama Department of Public Health The Alabama Department of Senior Services The Alabama Department of Human Resources 32 The Alabama Cooperative Extension Services Alabama Department of Rehabilitation Services The Alabama Rural Health Association The American Red Cross disaster relief services to military CPR First Aid Safety classes The Area Agency on Aging of West Alabama provides services to the elderly The Alabama Head Injury Foundation serves those disabled by brain or spinal cord injury The Arc of Tuscaloosa job skills training and placement for adults aged 21 and older Arts n Autism provides autism services to children Big Brothers Big Sisters volunteers providing oneon one help to at risk children

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Boy Scouts of America Black Warrior Council fitness and leadership opportunities for young men Boys Girls Club of West Alabama education recreation and leadership programs for children and youth Maude Whatley Health Center primary and mental health care to medically underserved residents Phoenix House halfway house for drug and alcohol dependent men and women Bradford Health Services clinical dependency treatment programs Police Athletic League of Tuscaloosa juvenile crime prevention program Caring Days Adult Day Care day care for adults with Alzheimer s Parkinson s and other forms of dementia Safe Center of Tuscaloosa free standing forensics center for victims of sexual assault Catholic Social Services of West Alabama multiple services for impoverished families Child Abuse Prevention Services prevention and self help services Community Service Programs of West Alabama agency dedicated to improving quality of life for low income and vulnerable populations Community Soup Bowl food assistance Easter Seals of West Alabama assistance to children and adults with physical handicaps Emergency Management County offices disaster preparedness Family Counseling Services individual and family counseling FOCUS on Senior Citizens senior programs Salvation Army emergency food and lodging Shelton State Ready to Work Program workplace development The Sickle Cell Disease Association of America services for those inflicted with Sickle Cell disease Tuscaloosa Mental Health Alliance mental health services support and outreach Success by Six prepares at risk four year olds for kindergarten Temporary Emergency Services help for those needing food clothing and emergency medicine Turning Point women s and children s safehouse Tuscaloosa Fire and Rescue services to protect life and property Tuscaloosa s One Place a family resource center Girl Scouts of North Central Alabama educations and recreational programs for girls The United Way creates partnerships with other service agencies to improve education income levels and health in the community Good Samaritan Clinic primary and dental health care to the uninsured with incomes at or below 200 percent of the federal poverty level The University of Alabama Lift program free job skills training and tutoring Habitat for Humanity of Tuscaloosa builds homes and provides furniture at discounted prices Tuscaloosa Chapter 1 Disabled Veteran Americans advocacy for disabled American Veterans and their families Health InfoNet of Alabama consumer health information Hospice of West Alabama health care support Indian Rivers Behavioral Health mental health facility Love Inc local churches helping people 211 Information and Referral Services linking clients to available resources 33

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY 34 County Type of Facility Facility Bibb Home Health Agency CV Home Health of Bibb County Hospital Bibb Medical Center Independent Clinical Laboratory Bibb Medical Center Laboratory Nursing Home Bibb Medical Center Nursing Home Rural Health Clinics Bibb Medical Associates Fayette Assisted Living Facility Morningview Estates End Stage Renal Disease Treatment Center Fayette Dialysis Home Health Agency Fayette Medical Center HomeCare Hospital Fayette Medical Center Independent Clinical Laboratory Fayette Medical Center Laboratory Nursing Home Fayette Medical Center Long Term Care Unit Rural Health Clinic Fayette Medical Center Greene End Stage Renal Disease Treatment Center Greene County Dialysis Home Health Agency Alabama HomeCare Hospital Greene County Health System Independent Clinical Laboratory Greene County Hospital Laboratory Nursing Home Greene County Residential Nursing Home Rural Health Clinic Greene County Hospital Physicians Clinic

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY Cont County Type of Facility Facility Hale Community Mental Health Center West Al Mental Health Center Hale County Home Health Agency Hale County Hospital Home Health Hospital Hale County Hospital Independent Clinical Laboratory Hale County Hospital Laboratory Nursing Homes Colonial Haven Care Rehab Center Moundville Health and Rehab LLC Rural Health Clinic Hale County Hospital Clinic Moundville Medical Associates Lamar Northwest Alabama Mental Health Center Community Mental Health Center Home Health Agencies Lamar County Home Care Encompass Health Home Health Generations of Vernon LLC Nursing Home Rural Health Clinics Millport Family Practice Clinic Sulligent Medical Clinic Fayette Medical Clinic Millport Pickens End Stage Renal Disease Treatment Center Pickens County Dialysis Federally Qualified Health Center Aliceville Family Practice Home Health Agencies Amedisys Home Health of Reform Encompass Health Home Health Nursing Homes Aliceville Manor Nursing Home Arbor Woods Health and Rehab Carrollton Primary Care Rural Health Clinic 35

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY Cont County 36 Type of Facility Facility Tuscaloosa Ambulatory Surgical Centers North River Surgical Center Tuscaloosa Endoscopy Center Tuscaloosa Surgical Center Vision Correction Center Assisted Living Facilities Crimson Village Hallmark Manor Hamrick Highlands Assisted Living Heritage Residential Care Village Bldg 2 Martinview Assisted Living West North River Village LLC Pine Valley Regency Retirement Village of Tuscaloosa Assisted Living Facilities Specialty Care Morning Pointe of Tuscaloosa Specialty Pathways Memory Care of Tuscaloosa The Tides at Crimson Village Traditions Way End State Renal Disease Treatment Centers DaVita Tuscaloosa Dialysis DaVita Crimson Dialysis DaVita Tuscaloosa University Dialysis RRC Northridge Northport Dialysis Federally Qualified Health Centers Crescent East Health Care West Tuscaloosa Health Center Whatley Health Services Inc DCH Home Health Care Agency Home Health Agencies Amedisys Home Health of Tuscaloosa DCH Home Health Care Agency Tuscaloosa County Home Care Hospices Alabama Hospice Care of Tuscaloosa Amedisys Hospice of Tuscaloosa Comfort Care Hospice of Tuscaloosa Hospice of West Alabama Hospice of West Alabama Inc Homecare SouthernCare New Beacon Tuscaloosa Oasis Health care Tuscaloosa ProHealth Hospice Tuscaloosa

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY Cont County Type of Facility Facility Tuscaloosa Hospitals Bryce Hospital DCH Regional Medical Center Mary S Harper Geriatric Medical Center Noland Hospital Tuscaloosa LLC Northport Medical Center Tuscaloosa VA Medical Center Independent Clinical Lab CVS Pharmacy 04819 CVS Pharmacy 03004 DCH Regional Medical Center Laboratory Laboratory Corporation of America Maude L Whatley Health Center PCR DX LLC Quest Diagnostics Tuscaloosa The Radiology Clinic Southern Blood Services Talecris Plasma Resources Inc Tuscaloosa Drug Company University Medical Center Laboratory Sav A Life of Tuscaloosa Inc Independent Physiological Labs Nursing Homes Aspire Physical Recovery Center of West Alabama Forest Manor Inc Glen Haven Health and Rehab LLC Heritage Health Care Rehab Inc Hunter Creek Health Rehab LLC Park Manor Health Rehab LLC Psychiatric Residential Treatment Facilities Brewer Porch Children s Center Rehabilitation Centers Champion Sport Medicine Rehab Center Restore Therapy Services Outpatient Tuscaloosa Rehabilitation Hand Center Inc Champion Sport Medicine Rehab Center Easter Seals West Alabama Northport Medical Center Sleep Lab Sleep Disorder Center 37

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APPENDIX A SU M M ARY Total Population 209 355 Births 2 630 Deaths 1 739 Median Age 33 8 Life Expectancy at Birth 77 0 Total Fertility Rate per 1 000 Females Aged 10 49 1 540 0 Number Marriages Issued TUSCALOOSA 2019 HEALTH PROFILE 1 226 Rate Number Divorces Granted 699 Rate Rates per 1 000 population P RE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 3 836 77 7 289 19 8 Births 2 630 12 6 185 12 6 Induced Terminations of Pregnancy 618 12 5 61 4 2 Estimated Total Fetal Losses 588 43 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 2 630 1 39 145 2 445 Rate 12 6 0 2 7 4 41 3 52 0 White 1 395 0 16 70 1 309 Rate 10 4 0 0 4 8 31 3 46 7 All Births Black and Other Rate 1 235 1 23 75 1 136 16 5 0 4 12 0 58 7 59 9 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Number Percent Number Percent 1 337 50 9 160 86 5 288 11 0 20 10 8 96 3 7 6 3 2 1 199 45 6 136 73 5 Percentages are of all births with known status for females in specified age group 38 Females Aged 10 19

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APPENDIX A TUSCALOOSA 2019 HEALTH PROFILE Cont INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 29 12 17 0 0 0 11 0 8 6 13 8 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births Neonatal Deaths Rate per 1 000 Births 9 3 6 0 0 0 3 4 2 2 4 9 0 0 0 0 0 0 20 9 11 0 0 0 7 6 6 5 8 9 0 0 0 0 0 0 Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group White Black and Other Total Male Female Total Male Female Total Male Female 209 355 100 780 108 575 134 441 66 468 67 973 74 914 34 312 40 602 0 4 12 532 6 427 6 105 7 143 3 681 3 462 5 389 2 746 2 643 5 9 12 364 6 250 6 114 7 049 3 568 3 481 5 315 2 682 2 633 10 14 11 951 6 098 5 853 6 843 3 465 3 378 5 108 2 633 2 475 15 44 96 501 47 141 49 360 60 256 30 527 29 729 36 245 16 614 19 631 45 64 47 218 22 429 24 789 31 623 15 717 15 906 15 595 6 712 8 883 65 84 25 611 11 447 14 164 19 054 8 715 10 339 6 557 2 732 3 825 3 178 988 2 190 2 473 795 1 678 705 193 512 Total 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 1 739 884 855 1 233 622 611 506 262 244 8 3 8 8 7 9 9 2 9 4 9 0 6 8 7 6 6 0 SE LEC T E D C AU SE S O F D E AT H Total Male Female White Number Rate Number Rate Number Rate Heart Disease 453 216 4 226 224 3 227 Cancer 316 150 9 171 169 7 145 Stroke 95 45 4 52 51 6 Accidents 90 43 0 65 CLRD 95 45 4 53 Diabetes 20 9 6 11 10 9 Influenza and Pneumonia 39 18 6 17 16 9 Alzheimer s Disease 88 42 0 29 28 8 Suicide 27 12 9 23 Homicide 19 9 1 16 0 0 0 0 HIV Disease Black and Other Number Rate Number Rate 209 1 314 233 6 139 185 5 133 5 204 151 7 112 149 5 43 39 6 66 49 1 29 38 7 64 5 25 23 0 69 51 3 21 28 0 52 6 42 38 7 77 57 3 18 24 0 9 8 3 14 10 4 6 8 0 22 20 3 26 19 3 13 17 4 59 54 3 72 53 6 16 21 4 22 8 4 3 7 22 16 4 5 6 7 15 9 3 2 8 1 0 7 18 24 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 39

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APPENDIX A TUSCALOOSA 2019 HEALTH PROFILE Cont A CCIDE NTA L DE ATH S All Ages Number D E AT HS B Y AGE GR O U P Ages 19 and Under Rate Number Rate Total Age Group All Accidents 90 43 0 4 7 4 Total Motor Vehicle 32 15 3 3 5 6 0 14 Suffocation Poisoning Smoke Fire and Flames Falls Rate 1 739 8 3 40 1 1 2 1 0 0 0 0 15 44 127 1 3 26 12 4 0 0 0 45 64 356 7 5 1 0 5 0 0 0 65 84 792 30 9 85 424 133 4 11 5 3 0 0 0 Drowning 4 1 9 0 0 0 Firearms 2 1 0 1 1 9 12 0 Other Accidents Number Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE C T E D C AN C E R SI T E D E AT HS Total All Cancers Male Female Number Rate Number Rate Number Rate 316 150 9 171 169 7 145 133 5 Trachea Bronchus Lung Pleura 87 41 6 57 56 6 30 27 6 Colorectal 26 12 4 11 10 9 15 13 8 Breast female 19 9 1 19 17 5 Prostate male 13 6 2 13 12 9 Pancreas 24 11 5 10 9 9 14 12 9 Leukemias 9 4 3 4 4 0 5 4 6 Non Hodgkin s Lymphomas 9 4 3 5 5 0 4 3 7 Ovary female 4 1 9 4 3 7 Brain and Other Nervous System 4 1 9 2 2 0 2 1 8 Stomach Uterus and Cervix female Esophagus Melanoma of Skin Other 8 3 8 5 5 0 3 2 8 10 4 8 10 9 2 7 3 3 5 5 0 2 1 8 3 1 4 2 2 0 1 0 9 93 57 36 Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 40

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APPENDIX A SU M M ARY Total Population 19 930 Births 187 Deaths 291 Median Age 42 2 Life Expectancy at Birth 74 3 Total Fertility Rate per 1 000 Females Aged 10 49 1 601 5 Number Marriages Issued PICKENS 2019 HEALTH PROFILE Divorces Granted 101 Rate Number 58 Rate Rates per 1 000 population PRE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 272 77 7 20 19 1 Births 187 9 4 15 14 2 Induced Terminations of Pregnancy 43 12 3 2 1 9 Estimated Total Fetal Losses 42 3 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 All Births 187 0 6 9 172 Rate 9 4 0 0 18 5 41 7 47 3 White 94 0 1 4 89 Rate 8 1 0 0 5 9 35 3 45 6 Black and Other Rate 93 0 5 5 83 11 1 0 0 32 4 48 6 49 3 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Females Aged 10 19 Number Percent Number Percent 118 63 1 13 86 7 21 11 2 0 0 0 4 2 1 0 0 0 104 55 6 11 73 3 Percentages are of all births with known status for females in specified age group 41

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APPENDIX A PICKENS 2019 HEALTH PROFILE Cont INFA NT RE LATE D M ORTA L I T Y B Y RAC E AN D M O T HE R S AGE GR O U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 2 2 0 0 0 0 10 7 21 3 0 0 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0 10 7 21 3 0 0 0 0 0 0 0 0 Rate per 1 000 Births Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GR O U P RAC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 19 930 10 014 9 916 11 568 5 985 5 583 8 362 4 029 4 333 0 4 1 026 542 484 497 253 244 529 289 240 5 9 1 038 552 486 536 296 240 502 256 246 10 14 1 083 567 516 559 289 270 524 278 246 15 44 7 417 3 922 3 495 4 088 2 246 1 842 3 329 1 676 1 653 45 64 5 480 2 660 2 820 3 348 1 701 1 647 2 132 959 1 173 65 84 3 456 1 609 1 847 2 270 1 090 1 180 1 186 519 667 430 162 268 270 110 160 160 52 108 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 291 158 133 195 108 87 96 50 46 14 6 15 8 13 4 16 9 18 0 15 6 11 5 12 4 10 6 SE LE C T E D C AU SE S O F D E AT H Total Male Female White Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 81 406 4 42 419 4 39 393 3 57 492 7 24 287 0 Cancer 57 286 0 36 359 5 21 211 8 33 285 3 24 287 0 Stroke 16 80 3 9 89 9 7 70 6 11 95 1 5 59 8 Accidents 14 70 2 11 109 8 3 30 3 8 69 2 6 71 8 CLRD 26 130 5 11 109 8 15 151 3 18 155 6 8 95 7 Diabetes 4 20 1 3 30 0 1 10 1 2 17 3 2 23 9 Influenza and Pneumonia 9 45 2 6 59 9 3 30 3 8 69 2 1 12 0 Alzheimer s Disease 11 55 2 4 39 9 7 70 6 10 86 4 1 12 0 Suicide 1 5 0 1 10 0 0 0 0 1 8 6 0 0 0 Homicide 2 10 0 2 20 0 0 0 0 1 8 6 1 12 0 HIV Disease 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 42 Black and Other

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PICKENS 2019 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages Number All Accidents Motor Vehicle D E AT HS B Y AGE GROU P Ages 19 and Under Rate Number Rate Total Age Group 14 70 2 0 0 0 Total 7 35 1 0 0 0 0 14 Number Rate 291 14 6 3 1 0 Suffocation 1 5 0 0 0 0 15 44 11 1 5 Poisoning 1 5 0 0 0 0 45 64 59 10 8 Smoke Fire and Flames 0 0 0 0 0 0 65 84 144 41 7 85 74 172 1 Falls 2 10 0 0 0 0 Drowning 0 0 0 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 3 0 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE C T E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate All Cancers 57 286 0 36 359 5 21 211 8 Trachea Bronchus Lung Pleura 14 70 2 10 99 9 4 40 3 Colorectal 5 25 1 4 39 9 1 10 1 Breast female 5 25 1 5 50 4 Prostate male 2 10 0 2 20 0 Pancreas 5 25 1 3 30 0 2 20 2 Leukemias 2 10 0 1 10 0 1 10 1 Non Hodgkin s Lymphomas 2 10 0 2 20 0 0 0 0 Ovary female 3 15 1 3 30 3 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 0 0 0 0 0 0 0 0 0 Uterus and Cervix female 1 5 0 1 10 1 Esophagus 3 15 1 3 30 0 0 0 0 0 0 0 0 0 0 0 0 0 15 11 4 Melanoma of Skin Other Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 43

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APPENDIX A SU M M ARY Total Population 13 805 Births 122 Deaths 196 Median Age 44 6 Life Expectancy at Birth 75 1 Total Fertility Rate per 1 000 Females Aged 10 49 1 643 5 Marriages Issued LAMAR 2019 HEALTH PROFILE Number 81 Rate Number Divorces Granted 104 Rate Rates per 1 000 population PRE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 155 67 9 14 17 9 Births 122 8 8 10 12 6 8 3 5 2 2 5 25 2 Induced Terminations of Pregnancy Estimated Total Fetal Losses Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GR O U P O F M O T HE R All Births Total 10 14 15 17 18 19 20 122 0 0 10 112 Rate 8 8 0 0 0 0 66 5 47 5 White 110 0 0 10 100 Rate 9 1 0 0 0 0 77 6 48 8 12 0 0 0 12 7 0 0 0 0 0 0 0 38 6 Black and Other Rate Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Percent Number Percent 54 44 3 8 80 0 Low Weight Births 7 5 7 1 10 0 Multiple Births 0 0 0 0 0 0 60 49 2 9 90 0 Births to Unmarried Women Medicaid Births Percentages are of all births with known status for females in specified age group 44 Females Aged 10 19 Number

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LAMAR 2019 HEALTH PROFILE Cont APPENDIX A INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 1 0 1 0 0 0 8 2 0 0 83 3 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 1 0 1 0 0 0 8 2 0 0 83 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 13 805 6 760 7 045 12 083 5 940 6 143 1 722 820 902 0 4 784 401 383 651 337 314 133 64 69 5 9 754 378 376 641 316 325 113 62 51 10 14 874 457 417 765 402 363 109 55 54 15 44 4 561 2 276 2 285 3 951 1 972 1 979 610 304 306 45 64 3 772 1 877 1 895 3 303 1 669 1 634 469 208 261 65 84 2 701 1 258 1 443 2 447 1 138 1 309 254 120 134 359 113 246 325 106 219 34 7 27 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 196 92 104 182 86 96 14 6 8 14 2 13 6 14 8 15 1 14 5 15 6 8 1 7 3 8 9 SE LEC T E D C AU SE S O F D E AT H Total Male Female White Black and Other Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 48 347 7 25 369 8 23 326 5 47 389 0 1 58 1 Cancer 42 304 2 20 295 9 22 312 3 39 322 8 3 174 2 Stroke 11 79 7 3 44 4 8 113 6 10 82 8 1 58 1 Accidents 12 86 9 7 103 6 5 71 0 11 91 0 1 58 1 CLRD 17 123 1 10 147 9 7 99 4 16 132 4 1 58 1 Diabetes 7 50 7 3 44 4 4 56 8 7 57 9 0 0 0 Influenza and Pneumonia 7 50 7 4 59 2 3 42 6 7 57 9 0 0 0 Alzheimer s Disease 6 43 5 1 14 8 5 71 0 5 41 4 1 58 1 Suicide 2 14 5 2 29 6 0 0 0 2 16 6 0 0 0 Homicide 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 HIV Disease 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 45

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APPENDIX A LAMAR 2019 HEALTH PROFILE Cont A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GROU P Ages 19 and Under Total Number Rate Number Rate Age Group 12 86 9 1 31 0 Total All Accidents Number Rate 196 14 2 Motor Vehicle 6 43 5 0 0 0 0 14 2 0 8 Suffocation 1 7 2 0 0 0 15 44 9 2 0 Poisoning 0 0 0 0 0 0 45 64 34 9 0 100 37 0 51 142 1 Smoke Fire and Flames 0 0 0 0 0 0 65 84 Falls 3 21 7 0 0 0 85 Drowning 0 0 0 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 2 1 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE CT E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate 42 304 2 20 295 9 22 312 3 Trachea Bronchus Lung Pleura 8 58 0 3 44 4 5 71 0 Colorectal 5 36 2 4 59 2 1 14 2 Breast female 3 21 7 3 42 6 Prostate male 2 14 5 2 29 6 Pancreas 3 21 7 1 14 8 2 28 4 Leukemias 0 0 0 0 0 0 0 0 0 Non Hodgkin s Lymphomas 2 14 5 1 14 8 1 14 2 Ovary female 0 0 0 0 0 0 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 0 0 0 0 0 0 0 0 0 Uterus and Cervix female 1 7 2 1 14 2 Esophagus 0 0 0 0 0 0 0 0 0 Melanoma of Skin 1 7 2 1 14 8 0 0 0 17 8 9 All Cancers Other Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 46

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APPENDIX A SU M M ARY Total Population 14 651 Births 193 Deaths 219 Median Age 40 8 Life Expectancy at Birth 71 1 Total Fertility Rate per 1 000 Females Aged 10 49 2 098 5 Marriages Issued HALE 2019 HEALTH PROFILE Divorces Granted Number 50 Rate Number 46 Rate Rates per 1 000 population PRE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 275 101 8 21 23 7 Births 193 13 2 11 12 5 Induced Terminations of Pregnancy 39 14 5 7 7 9 Estimated Total Fetal Losses 43 3 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GRO U P O F M O T HE R Total 10 14 15 17 18 19 20 All Births 193 0 4 7 182 Rate 13 2 0 0 15 5 40 6 68 0 White 68 0 1 2 65 Rate 11 4 0 0 11 3 34 0 67 7 Black and Other Rate 125 0 3 5 117 14 4 0 0 17 6 44 0 68 1 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Females Aged 10 19 Number Percent Number Percent 127 65 8 10 90 9 14 7 3 0 0 0 4 2 1 0 0 0 119 61 7 9 81 8 Percentages are of all births with known status for females in specified age group 47

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APPENDIX A HALE 2019 HEALTH PROFILE Cont INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 4 0 4 1 0 1 20 7 0 0 32 0 90 9 0 0 125 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 1 0 1 20 7 0 0 32 0 90 9 0 0 125 0 Rate per 1 000 Births Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 14 651 6 950 7 701 5 963 2 956 3 007 8 688 3 994 4 694 0 4 990 525 465 331 179 152 659 346 313 5 9 906 462 444 357 189 168 549 273 276 10 14 947 495 452 348 170 178 599 325 274 15 44 5 138 2 441 2 697 1 883 938 945 3 255 1 503 1 752 45 64 3 785 1 757 2 208 1 599 812 787 2 186 945 1 241 65 84 2 523 1 166 1 357 1 268 605 663 1 255 561 694 362 104 258 177 63 114 185 41 144 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 219 111 108 89 41 48 130 70 60 14 9 16 0 14 0 14 9 13 9 16 0 15 0 17 5 12 8 SE LE C T E D C AU SE S O F D E AT H Total Male Female White Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 65 443 7 38 546 8 27 350 6 27 452 8 38 437 4 Cancer 26 177 5 13 187 1 13 168 8 12 201 2 14 161 1 Stroke 20 136 5 11 158 3 9 116 9 4 67 1 16 184 2 Accidents 8 54 6 6 86 3 2 26 0 3 50 3 5 57 6 CLRD 9 61 4 3 43 2 6 77 9 5 83 9 4 46 0 Diabetes 3 20 5 3 43 2 0 0 0 0 0 0 3 34 5 Influenza and Pneumonia 5 34 1 4 57 6 1 13 0 1 16 8 4 46 0 Alzheimer s Disease 8 54 6 4 57 6 4 51 9 6 100 6 2 23 0 Suicide 2 13 7 0 0 0 2 26 0 2 33 5 0 0 0 Homicide 1 6 8 0 0 0 1 13 0 0 0 0 1 11 5 HIV Disease 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 48 Black and Other

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HALE 2019 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GROU P Ages 19 and Under Total Number Rate Number Rate Age Group All Accidents 8 54 6 2 53 8 Total Motor Vehicle 3 20 5 0 0 0 0 14 Number Rate 219 14 9 6 2 1 Suffocation 1 6 8 0 0 0 15 44 15 2 9 Poisoning 0 0 0 0 0 0 45 64 55 14 5 Smoke Fire and Flames 2 13 7 1 26 9 65 84 90 35 7 Falls 1 6 8 0 0 0 85 53 146 4 Drowning 1 6 8 1 26 9 Firearms 0 0 0 0 0 0 Other Accidents 0 0 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE CT E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate 26 177 5 13 187 1 13 168 8 Trachea Bronchus Lung Pleura 8 54 6 6 86 3 2 26 0 Colorectal 1 6 8 1 14 4 0 0 0 Breast female 2 13 7 2 26 0 Prostate male 1 6 8 1 14 4 Pancreas 2 13 7 1 14 4 1 13 0 Leukemias 0 0 0 0 0 0 0 0 Non Hodgkin s Lymphomas 0 0 0 0 0 0 0 0 0 Ovary female 1 6 8 1 13 0 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 0 0 0 0 0 0 0 0 0 Uterus and Cervix female 2 13 7 2 26 0 Esophagus 1 6 8 0 0 0 1 13 0 Melanoma of Skin 0 0 0 0 0 0 0 0 0 Other 8 4 4 All Cancers Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 49

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APPENDIX A SU M M ARY Total Population 8 111 Births 86 Deaths 92 Median Age 43 9 Life Expectancy at Birth 76 4 Total Fertility Rate per 1 000 Females Aged 10 49 1 878 5 Marriages Issued GREENE 2019 HEALTH PROFILE Number 46 Rate Number Divorces Granted 9 Rate Rates per 1 000 population PR E GN AN C Y N ATAL I T Y Females Aged 15 44 Number Estimated Pregnancies Females Aged 10 19 Rate Number Rate 127 93 5 20 39 8 Births 86 10 6 13 25 8 Induced Terminations of Pregnancy 22 16 1 4 8 0 Estimated Total Fetal Losses 19 3 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 86 1 5 7 73 10 6 3 8 34 9 73 2 54 5 All Births Rate White 7 0 1 1 5 Rate 4 7 0 0 92 6 138 9 27 0 Black and Other Rate 79 1 4 6 68 11 9 4 3 30 2 67 9 58 9 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Number Percent Number Percent Births to Unmarried Women 66 76 7 10 76 9 Low Weight Births 19 22 1 2 15 4 4 4 7 0 0 0 64 74 4 13 100 0 Multiple Births Medicaid Births Percentages are of all births with known status for females in specified age group 50 Females Aged 10 19

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GREENE 2019 HEALTH PROFILE Cont APPENDIX A INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 2 0 2 0 0 0 23 3 0 0 25 3 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 1 0 1 0 0 0 11 6 0 0 12 7 0 0 0 0 0 0 1 0 1 0 0 0 11 6 0 0 12 7 0 0 0 0 0 0 Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 8 111 3 829 4 282 1 500 735 765 6 611 3 094 3 517 0 4 466 247 219 66 27 39 400 220 180 5 9 480 250 230 64 29 35 416 221 195 10 14 509 245 264 64 35 29 445 210 235 15 44 2 691 1 328 1 363 341 179 162 2 350 1 149 1 201 45 64 2 075 941 1 134 475 244 232 1 599 697 902 65 84 1 646 740 906 429 200 229 1 217 540 677 244 78 166 60 21 39 184 57 127 85 M O RTAL I T Y All Races Black and Other Total Male Female Total Male Female Total Male Female 92 61 31 22 13 9 70 48 22 11 3 15 9 7 2 14 7 17 7 11 8 10 6 15 5 6 3 Deaths Rate per 1 000 Population White SE LE C T E D C AU SE S O F D E AT H Total Male Female White Black and Other Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 25 308 2 17 444 0 8 186 8 4 266 7 21 317 7 Cancer 16 197 3 10 261 2 6 140 1 4 266 7 12 181 5 Stroke 7 86 3 4 104 5 3 70 1 2 133 3 5 75 6 Accidents 7 86 3 5 130 6 2 46 7 1 66 7 6 90 8 CLRD 6 74 0 3 78 3 3 70 1 3 200 0 3 45 4 Diabetes 4 49 3 2 52 2 2 46 7 1 66 7 3 45 4 Influenza and Pneumonia 2 24 7 1 26 1 1 23 4 1 66 7 1 15 1 Alzheimer s Disease 2 24 7 2 52 2 0 0 0 1 66 7 1 15 1 Suicide 2 24 7 2 52 2 0 0 0 2 133 3 0 0 0 Homicide 1 12 3 1 26 1 0 0 0 0 0 0 1 15 1 HIV Disease 1 12 3 1 26 1 0 0 0 0 0 0 1 15 1 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 51

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GREENE 2019 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GRO UP Ages 19 and Under Total Number Rate Number Rate Age Group 7 86 3 1 51 9 Total All Accidents Number Rate 92 11 3 Motor Vehicle 5 61 6 0 0 0 0 14 2 1 4 Suffocation 0 0 0 0 0 0 15 44 10 3 7 Poisoning 0 0 0 0 0 0 45 64 22 10 6 Smoke Fire and Flames 0 0 0 0 0 0 65 84 40 24 3 Falls 0 0 0 0 0 0 85 18 73 8 Drowning 1 12 3 1 51 9 Firearms 0 0 0 0 0 0 Other Accidents 1 0 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE CT E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate 16 197 3 10 261 2 6 140 1 Trachea Bronchus Lung Pleura 5 61 6 3 78 3 2 46 7 Colorectal 1 12 3 1 26 1 0 0 0 Breast female 1 12 3 1 23 4 Prostate male 3 37 0 3 78 3 Pancreas 1 12 3 0 0 0 1 23 4 Leukemias 0 0 0 0 0 0 0 0 0 Non Hodgkin s Lymphomas 0 0 0 0 0 0 0 0 0 Ovary female 1 12 3 1 23 4 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 1 12 3 1 26 1 0 0 0 Uterus and Cervix female 0 0 0 0 0 0 Esophagus 0 0 0 0 0 0 0 0 0 Melanoma of Skin 0 0 0 0 0 0 0 0 0 Other 3 2 1 All Cancers Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 52

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APPENDIX A SU M M ARY Total Population 16 302 Births 197 Deaths 217 Median Age 43 9 Life Expectancy at Birth 74 0 Total Fertility Rate per 1 000 Females Aged 10 49 2 153 5 Number Marriages Issued FAYETTE 2019 HEALTH PROFILE Divorces Granted 101 Rate Number 37 Rate Rates per 1 000 population PRE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 254 93 5 24 26 1 Births 197 12 1 19 20 8 Induced Terminations of Pregnancy 16 5 9 1 1 1 Estimated Total Fetal Losses 41 4 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GRO U P O F M O T HE R Total 10 14 15 17 18 19 20 All Births 197 0 4 15 178 Rate 12 1 0 0 15 0 84 5 63 3 White 178 0 3 14 161 Rate 12 7 0 0 13 2 92 1 66 0 Black and Other Rate 19 0 1 1 17 8 2 0 0 26 0 39 1 45 5 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Females Aged 10 19 Number Percent Number Percent Births to Unmarried Women 87 44 2 11 57 9 Low Weight Births 23 11 7 3 15 8 Multiple Births 12 6 1 0 0 0 Medicaid Births 97 49 5 14 73 7 Percentages are of all births with known status for females in specified age group 53

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APPENDIX A FAYETTE 2019 HEALTH PROFILE Cont INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 2 2 0 0 0 0 10 2 11 2 0 0 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births Neonatal Deaths Rate per 1 000 Births 1 1 0 0 0 0 5 1 5 6 0 0 0 0 0 0 0 0 1 1 0 0 0 0 5 1 5 6 0 0 0 0 0 0 0 0 Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 16 302 7 937 8 365 13 980 6 817 7 163 2 322 1 120 1 202 0 4 902 447 455 698 364 334 204 83 121 5 9 956 475 481 759 384 375 197 91 106 10 14 997 526 471 857 441 416 140 85 55 15 44 5 496 2 779 2 717 4 716 2 379 2 337 780 400 380 45 64 4 406 2 158 2 248 3 828 1 873 1 955 578 285 293 65 84 3 220 1 440 1 780 2 847 1 278 1 569 373 162 211 325 112 213 275 98 177 50 14 36 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 217 126 91 185 111 74 32 15 17 13 3 15 9 10 9 13 2 16 3 10 3 13 8 13 4 14 1 SE LEC T E D C AU SE S O F D E AT H Total Male Female White Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 51 312 8 35 441 0 16 191 3 43 307 6 8 344 5 Cancer 33 202 4 20 252 0 13 155 4 28 200 3 5 215 3 Stroke 8 49 1 4 50 4 4 47 8 8 57 2 0 0 0 Accidents 15 92 0 11 138 6 4 47 8 13 93 0 2 86 1 CLRD 28 171 8 17 214 2 11 131 5 23 164 5 5 215 3 Diabetes 6 36 8 4 50 4 2 23 9 5 35 8 1 43 1 Influenza and Pneumonia 5 30 7 3 37 8 2 23 9 3 21 5 2 86 1 Alzheimer s Disease 9 55 2 2 25 2 7 83 7 8 57 2 1 43 1 Suicide 5 30 7 3 37 8 2 23 9 5 35 8 0 0 0 Homicide 2 12 3 2 25 2 0 0 0 2 14 3 0 0 0 HIV Disease 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 54 Black and Other

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FAYETTE 2019 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GRO UP Ages 19 and Under Total Number Rate Number Rate Age Group 15 92 0 1 26 5 Total Motor Vehicle 3 18 4 1 26 5 0 14 Suffocation 1 6 1 0 0 0 15 44 Poisoning 5 30 7 0 0 0 Smoke Fire and Flames 1 6 1 0 0 0 Falls 2 12 3 0 0 0 85 Drowning 1 6 1 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 2 0 All Accidents Number Rate 217 13 3 2 0 7 15 2 7 45 64 51 11 6 65 84 104 32 3 45 138 5 Rates are per 100 000 population in specified categories SE LE C T E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate 33 202 4 20 252 0 13 155 4 Trachea Bronchus Lung Pleura 7 42 9 4 50 4 3 35 9 Colorectal 6 36 8 3 37 8 3 35 9 Breast female 2 12 3 2 23 9 Prostate male 4 24 5 4 50 4 Pancreas 2 12 3 0 0 0 2 23 9 Leukemias 1 6 1 0 0 0 1 12 0 Non Hodgkin s Lymphomas 0 0 0 0 0 0 0 0 0 Ovary female 0 0 0 0 0 0 Brain and Other Nervous System 1 6 1 1 12 6 0 0 0 Stomach 0 0 0 0 0 0 0 0 0 Uterus and Cervix female 0 0 0 0 0 0 Esophagus 1 6 1 1 12 6 0 0 0 Melanoma of Skin 0 0 0 0 0 0 0 0 0 Other 9 7 2 All Cancers Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 55

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APPENDIX A SU M M ARY Total Population 22 394 Births 246 Deaths 264 Median Age 40 0 Life Expectancy at Birth 73 6 Total Fertility Rate per 1 000 Females Aged 10 49 1 956 0 Number Marriages Issued BIBB 2019 HEALTH PROFILE 126 Rate Number Divorces Granted 0 Rate Rates per 1 000 population PRE GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 305 81 5 19 16 2 Births 246 11 0 15 12 7 9 2 4 1 0 8 50 3 Induced Terminations of Pregnancy Estimated Total Fetal Losses Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTH S B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 All Births 246 0 2 13 231 Rate 11 0 0 0 5 8 56 1 59 6 White 195 0 2 7 186 Rate 11 3 0 0 7 2 37 6 60 1 Black and Other Rate 51 0 0 6 45 9 8 0 0 0 0 132 7 57 4 Rates are per 1 000 females in specified age group Births with unknown age of mother are included in the age group 20 L I V E B I RT HS Females Aged 15 44 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Number Percent Number Percent 112 45 5 12 80 0 27 11 0 0 0 0 6 2 4 0 0 0 121 49 2 9 60 0 Percentages are of all births with known status for females in specified age group 56 Females Aged 10 19

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APPENDIX A BIBB 2019 HEALTH PROFILE Cont INFA NT RE LATE D M ORTA L I T Y B Y R AC E AN D M O T HE R S AGE GRO U P All Ages Ages 10 19 All Races White Black and Other All Races White Black and Other 5 4 1 0 0 0 20 3 20 5 19 6 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 3 3 0 0 0 0 12 2 15 4 0 0 0 0 0 0 0 0 2 1 1 0 0 0 8 1 5 1 19 6 0 0 0 0 0 0 Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 9 E STIMATE D POP U L AT I O N S B Y AGE GRO U P R AC E AN D SE X All Races Age Group Total White Black and Other Total Male Female Total Male Female Total Male Female 22 394 11 929 10 465 17 191 8 766 8 425 5 203 3 163 2 040 0 4 1 246 622 624 964 482 482 282 140 142 5 9 1 198 631 567 919 482 437 279 149 130 10 14 1 269 667 602 976 529 447 293 138 155 15 44 8 890 5 145 3 745 6 332 3 347 2 985 2 558 1 798 760 45 64 6 058 3 197 2 861 4 801 2 484 2 317 1 257 713 544 65 84 3 344 1 544 1 800 2 880 1 339 1 541 464 205 259 389 123 266 319 103 216 70 20 50 85 M O RTAL I T Y All Races Deaths Rate per 1 000 Population White Black and Other Total Male Female Total Male Female Total Male Female 264 135 129 219 108 111 45 27 18 11 8 11 3 12 3 12 7 12 3 13 2 8 6 8 5 8 8 SE LEC T E D C AU SE S O F D E AT H Total Male Female White Black and Other Number Rate Number Rate Number Rate Number Rate Number Rate Heart Disease 74 330 4 38 318 6 36 344 0 57 331 6 17 326 7 Cancer 50 223 3 28 234 7 22 210 2 45 261 8 5 96 1 Stroke 19 84 8 11 92 2 8 76 4 16 93 1 3 57 7 Accidents 15 67 0 10 83 8 5 47 8 14 81 4 1 19 2 CLRD 15 67 0 7 58 7 8 76 4 15 87 3 0 0 0 Diabetes 6 26 8 2 16 8 4 38 2 5 29 1 1 19 2 Influenza and Pneumonia 4 17 9 1 8 4 3 28 7 2 11 6 2 38 4 Alzheimer s Disease 10 44 7 4 33 5 6 57 3 7 40 7 3 57 7 Suicide 3 13 4 2 16 8 1 9 6 3 17 5 0 0 0 Homicide 4 17 9 3 25 1 1 9 6 0 0 0 4 76 9 HIV Disease 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 57

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BIBB 2019 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages Number All Accidents Motor Vehicle D E AT HS B Y AGE GROU P Ages 19 and Under Rate Number Total Rate Age Group 15 67 0 2 40 1 Total 6 26 8 1 20 0 0 14 Number Rate 264 11 8 5 1 3 Suffocation 3 13 4 1 20 0 15 44 19 2 1 Poisoning 3 13 4 0 0 0 45 64 61 10 1 Smoke Fire and Flames 1 4 5 0 0 0 65 84 136 40 7 85 43 110 5 Falls 1 4 5 0 0 0 Drowning 0 0 0 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 1 0 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE CT E D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate All Cancers 50 223 3 28 234 7 22 210 2 Trachea Bronchus Lung Pleura 14 62 5 9 75 4 5 47 8 Colorectal 0 0 0 0 0 0 0 0 0 Breast female 1 4 5 1 9 6 Prostate male 0 0 0 0 0 0 Pancreas 3 13 4 2 16 8 1 9 6 Leukemias 2 8 9 1 8 4 1 9 6 Non Hodgkin s Lymphomas 6 26 8 3 25 1 3 28 7 Ovary female 3 13 4 3 28 7 Brain and Other Nervous System 1 4 5 1 8 4 0 0 0 Stomach 0 0 0 0 0 0 0 0 0 Uterus and Cervix female 0 0 0 0 0 0 Esophagus 1 4 5 1 8 4 0 0 0 0 0 0 0 0 0 0 0 0 14 11 8 Melanoma of Skin Other Rates are per 100 000 population in specified categories Measurements are based on small denominators should be used with caution Rates and ratios based on a denominator of less than 50 births or 1 000 population are shaded Estimated pregnancies are the sum of births induced terminations of pregnancy abortions and estimated total fetal losses Estimated total fetal losses are equal to the sum of 20 percent of births and 10 percent of induced terminations of pregnancy The total fertility rate is the sum of age specific birth rates multiplied by the width of the intervals i e five years A total fertility rate of 2 100 births per 1 000 females ages 10 49 years would maintain the current population Estimated populations are from the U S Census Bureau See Appendix B for other definitions and formulas 58

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STATE OF ALABAMA MEDICAL STATISTIC MAPS APPENDIX A Percent of Obesity by Public Health Districts Alabama 2019 Lauderdale Limestone Jackson Madison Colbert Lawrence Franklin 34 7 Morgan Dekalb Marshall Northern Marion Cherokee Cullman Winston Blount 35 1 Fayette 41 1 Cleburne Talladega Jefferson Tuscaloosa Calhoun St Clair Jefferson Pickens 34 4 Northeastern Walker Lamar Etowah Clay Shelby West Central Bibb Greene Coosa Tallapoosa Chambers 34 7 Chilton Hale Randolph East Central Perry Autauga Sumter Elmore Lee Macon Dallas Marengo Russell Montgomery Lowndes Choctaw 38 2 Southwestern Wilcox Butler Crenshaw Monroe 38 8 Southeastern Henry Conecuh Coffee Covington Escambia 37 3 Barbour Pike Clarke Washington Bullock Geneva Dale Houston Mobile Mobile Baldwin Source 2019 Alabama Behavioral Risk Factor Surveillance system BRFSS 59

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STATE OF ALABAMA MEDICAL STATISTIC MAPS Cont APPENDIX A Dental Health Professional Shortage Areas October 2017 Lauderdale 17 Limestone 10 Colbert 17 Lawrence Franklin Marion 12 Winston 17 17 14 Morgan 12 19 Jackson Madison Dekalb Marshall 19 14 Cherokee Cullman 19 16 17 Blount Lamar 15 Walker Fayette 19 19 19 Calhoun St Clair 19 13 Jefferson 13 Pickens Talladega 14 15 Coosa 15 21 17 Perry 17 Dallas Macon 19 17 Lowndes Choctaw 19 Lee Montgomery 21 19 19 21 Washington Barbour 19 Pike Butler 19 Monroe 19 19 21 Clarke Russell Bullock 19 Wilcox 15 19 17 Autauga 19 Marengo Chambers 19 Elmore 21 Sumter 16 Tallapoosa 14 Chilton Hale Randolph 16 Bibb 21 Clay Shelby Greene 19 Cleburne Tuscaloosa 19 19 Etowah 19 19 Crenshaw Conecuh Coffee 19 19 Covington Escambia 19 17 17 Geneva Henry Dale 19 14 14 Houston 14 Mobile 17 Baldwin 17 HPSA Designation Type Low income Non designated Numerals indicate HPSA Scores Range 1 26 Niko Phillips 334 206 3807 or Niko Phillips adph state al us 61

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STATE OF ALABAMA MEDICAL STATISTIC MAPS Cont APPENDIX A Mental Health Professional Shortage Areas August 2018 Lauderdale 11 Limestone 12 Colbert 11 Lawrence Franklin Marion 12 Winston 19 15 Morgan 12 11 Jackson Madison Dekalb Marshall 17 15 Cherokee Cullman 19 16 17 Blount Lamar 18 Walker Fayette 19 19 19 Talladega Bibb Coosa 18 11 Perry 16 Dallas 19 Macon 17 16 Lowndes Choctaw 18 Lee Montgomery 20 18 Monroe 18 Washington Barbour 17 Pike Butler 18 17 17 20 Clarke Russell Bullock 16 Wilcox 17 17 16 Autauga 18 Marengo Chambers 17 Elmore 20 Sumter 18 Tallapoosa 18 Chilton Hale Randolph 18 11 Greene 18 Clay Shelby 18 10 Cleburne 18 Tuscaloosa 18 10 18 18 18 Calhoun St Clair Jefferson Pickens 17 Etowah 18 17 Crenshaw Conecuh Coffee 18 19 Covington Escambia 18 18 18 Geneva Henry Dale 17 17 17 Houston 17 Mobile 19 Baldwin 5 HPSA Designation Type Geographic Low income Non designated Numerals indicate HPSA Scores Range 1 25 Niko Phillips 334 206 3807 or Niko Phillips adph state al us 62

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STATE OF ALABAMA MEDICAL STATISTIC MAPS Cont APPENDIX A Primary Care Health Professional Shortage Areas January 2019 Lauderdale 14 Limestone 15 Colbert 14 Lawrence Franklin Marion 11 Winston 15 9 Morgan 15 10 Jackson Madison Dekalb Marshall 14 10 Cherokee Cullman 15 13 15 Blount Lamar 15 Walker Fayette 15 16 15 15 Talladega Coosa 16 16 Perry 19 Sumter 12 18 20 Elmore 18 15 Monroe 18 Washington 20 Barbour 20 Pike Butler 18 Russell 21 18 Clarke Lee 16 Bullock 22 Wilcox 18 21 18 16 Lowndes Choctaw 14 Chambers Macon Montgomery 15 17 20 16 Dallas Marengo 16 Autauga 17 Tallapoosa 14 Chilton Hale Randolph 12 Bibb 20 Clay Shelby Greene 18 Cleburne 13 Tuscaloosa 23 13 9 15 13 Calhoun St Clair Jefferson Pickens 15 Etowah 15 11 Crenshaw Coffee 15 14 Henry Dale Conecuh 11 15 Covington Escambia 11 16 Geneva 14 Houston Mobile 13 Baldwin 15 HPSA Designation Type Geographic Low income Non designated Numerals indicate HPSA Scores Range 1 25 Niko Phillips 334 206 3807 or Niko Phillips adph state al us 63

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APPENDIX B C O UNT Y H E ALTH RA NKIN G S ROA DMA PS C O MPAR E COU NTIES 2021 RA NKIN G S Health Outcomes Length of Life Premature Death Quality of Life Poor or Fair Health Poor Physical Health Days Poor Mental Health Days Low Birthweight Alabama Fayette Lamar Bibb Greene Hale Tuscaloosa Pickens 9 800 10 500 11 200 12 200 12 900 13 700 8 500 8 800 21 24 25 24 34 29 21 27 4 4 5 1 5 2 4 9 6 0 5 3 4 4 5 2 4 9 5 5 5 8 5 3 5 8 5 6 5 0 5 3 10 11 9 10 16 12 11 13 Health Factors Health Behaviors Adult Smoking 20 24 24 23 27 24 20 24 Adult Obesity 36 38 34 37 38 45 36 39 5 5 7 1 7 1 7 6 3 8 6 3 7 3 6 8 Food Environment Index Physical Inactivity 29 30 31 33 24 32 28 26 Access to Exercise Opportunities 61 34 10 16 6 30 76 6 Excessive Drinking 15 15 15 15 10 12 15 13 Alcohol impaired Driving Deaths 27 22 23 30 32 32 34 15 Sexually Transmitted Infections 583 4 461 5 258 1 613 2 1 200 5 1 505 5 890 7 594 8 Teen Births 29 37 39 38 49 35 21 33 Clinical Care 12 12 12 11 12 11 10 12 Primary Care Physicians Uninsured 1 530 1 970 1 1 870 1 2 060 1 4 910 1 1 390 1 2 490 1 Dentists 2 000 1 3 260 1 4 600 1 4 480 1 8 110 1 7 330 1 2 010 1 4 980 1 Mental Health Providers 920 1 8 150 1 6 900 1 3 730 1 8 110 1 7 330 1 680 1 4 980 1 Preventable Hospital Stays 5 466 4 667 5 917 6 690 6 410 6 585 5 624 5 829 Mammography Screening 40 38 38 33 29 31 44 44 Flu Vaccinations 43 47 43 40 32 34 46 46 Social Economic Factors High School Completion Some College 86 83 82 79 79 84 88 82 61 51 48 40 52 46 64 54 3 0 3 1 3 1 3 1 5 6 3 9 2 7 3 5 22 23 22 26 46 31 20 34 5 2 5 2 5 2 5 0 5 7 6 2 5 2 5 8 Children in Single parent Households 32 28 24 31 72 51 35 40 Social Associations 12 3 8 5 7 2 8 5 8 5 6 8 10 7 10 0 480 162 89 669 209 402 166 Injury Deaths 84 102 92 106 84 90 64 83 Physical Environment Unemployment Children in Poverty Income Inequality Violent Crime 9 2 9 2 8 8 10 0 9 1 9 4 7 4 9 1 Drinking Water Violations Air Pollution Particulate Matter Yes No No No No No No Severe Housing Problems 14 12 10 9 19 15 16 13 Driving Alone to Work 86 86 90 87 73 89 86 82 Long Commute Driving Alone 35 44 44 52 42 53 26 54 Compare across states with caution Note Blank values reflect unreliable or missing data 64

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METHODOLOGY THE BURDEN OF DIABETES IN ALABAMA Diabetes is an epidemic in the United States According to the Centers for Disease Control and Prevention CDC over 34 million Americans have diabetes and face its devastating consequences What s true nationwide is also true in Alabama ALABAMA S DIABETES EPIDEMIC Approximately 553 000 people in Alabama or 14 6 of the adult population have diagnosed diabetes An additional 119 000 people in Alabama have diabetes but don t know it greatly increasing their health risk There are 1 316 000 people in Alabama 34 6 of the adult population who have prediabetes with blood glucose levels higher than are higher than normal but not yet high enough to be diagnosed as diabetes Every year an estimated 41 000 adults in Alabama are diagnosed with diabetes DIABETES IS EXPENSIVE People with diabetes have medical expenses approximately 2 3 times higher than those who do not have diabetes Total direct medical expenses for diagnosed diabetes in Alabama were estimated at 4 2 billion in 2017 In addition another 1 7 billion was spent on indirect costs from lost productivity due to diabetes APPENDIX C Diagnosed diabetes costs an estimated 5 9 billion in Alabama each year The serious complications include heart disease stroke amputation end stage kidney disease blindness and death IMPROVING LIVES PREVENTING DIABETES AND FINDING A CURE In 2019 the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health invested 30 465 029 in diabetesrelated research projects in Alabama The Division of Diabetes Translation at the CDC provided 1 821 128 in diabetes prevention and educational grants in Alabama in 2018 Sources include Diabetes Prevalence 2016 state diagnosed diabetes prevalence cdc gov diabetes data 2017 state undiagnosed diabetes prevalence Dall et al The Economic Burden of Elevated Blood Glucose Levels in 2017 Diabetes Care December 2019 vol 42 Diabetes Incidence 2016 state diabetes incidence rates cdc gov diabetes data Cost America Diabetes Association Economic Costs of Diabetes in the U S in 2017 Diabetes Care May 2018 Research expenditures 2019 NIDDK funding Projectreporter nih gov 2018 CDC diabetes funding www cdc gov fundingprofiles Learn more at diabetes org 1 800 DIABETES 800 342 2383 65

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THE BURDEN OF DIABETES IN ALABAMA Cont APPENDIX C Counties with the Highest Rates of Diabetes and Ratios of Citizens to Primary Care Providers in Alabama Lauderdale Limestone Madison Jackson Colbert Lawrence Franklin Morgan Marion Winston Dekalb Marshall Cherokee Cullman Etowah Blount Lamar Fayette Walker Calhoun St Clair Cleburne Jefferson Talladega Pickens Tuscaloosa Bibb Coosa Greene Tallapoosa Chilton Hale Randolph Clay Shelby Perry Chambers Lee Elmore Autauga Sumter Macon Marengo Dallas Russell Montgomery Choctaw Bullock Lowndes Wilcox Barbour Pike Butler Clarke Monroe Crenshaw Coffee Conecuh Washington Dale Henry Covington Houston Escambia Geneva Mobile Baldwin Alabama counties with 5 or fewer providers and diabetes prevalence above 10 6 Alabama counties with 6 10 providers and diabetes prevalence above 10 6 Ratio of citizens to primary care providers higher than 6 000 1 Data Source 2017 County Health Rankings www countyhealthrankings org and BRFSS 2015 66

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THE BURDEN OF DIABETES IN ALABAMA Cont APPENDIX C Alabama Poverty Vision Loss and Diabetes Prevalence by County Lauderdale 18 7 Limestone 13 6 Lawrence 16 6 Franklin 23 1 Marion 20 2 Morgan 15 0 Winston 20 1 Jackson 22 0 Madison 14 2 Colbert 16 7 Cullman 17 2 Fayette 20 6 Walker 23 5 Cherokee 18 6 Etowah 22 0 Blount 17 5 Lamar 20 6 Dekalb 24 0 Marshall 22 0 Calhoun 20 5 St Clair 14 3 Cleburne 17 0 Jefferson 19 5 Talladega 22 5 Pickens 25 0 Tuscaloosa 18 0 Bibb 18 1 Greene 33 2 Hale 28 1 Dallas 35 2 Marengo 25 6 Tallapoosa Chambers 21 3 21 3 Lee 25 2 Elmore 14 4 Autauga 13 1 Sumter 38 1 Choctaw 25 0 Coosa 18 8 Chilton 18 1 Perry 46 9 Randolph 20 4 Clay 19 5 Shelby 9 6 Macon 32 1 Montgomery 22 5 Lowndes 31 4 Bullock 35 1 Wilcox 33 7 Clarke 24 9 Crenshaw 21 2 Conecuh 30 6 Washington 18 5 Barbour 25 4 Pike 26 4 Butler 25 0 Monroe 25 3 Escambia 25 1 Russell 20 9 Covington 20 8 Dale 22 4 Coffee 16 8 Geneva 23 9 Henry 17 3 Houston 20 1 Mobile 19 6 Baldwin 13 0 Under 12 in poverty 12 15 4 in poverty 15 5 19 in poverty 19 1 24 9 in poverty 25 and above in poverty Source Alabama Possible American Community Survey ACS0 5 Year Activity Table B 10103 and BRFSS 2015 3 73 or more of county residents report vision loss Diabetes prevalence at or above 12 2 among Medicare Medicaid and BCBS beneficiaries15 5 19 in poverty 3 73 or more of county residents report vision loss AND Diabetes prevalence at or above 12 2 among Medicare medicaid and BCBS beneficiaries 67

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APPENDIX C THE BURDEN OF DIABETES IN ALABAMA Cont APPENDIX C Diagnosed Diabetes Total Adults with Diabetes Age adjusted Percentage Alabama 14 12 10 8 6 4 2 Vertical dotted line indicates major changes to the survey methods in 2011 http www cdc gov SurveillancePractice reports brfss brfss html Horizontal dotted line indicates No Data Suppressed Data or both Diagnosed Diabetes Total Adults with Diabetes Age adjusted Percentage Alabama Total Year Percentage LL 2004 7 9 7 0 8 8 2005 9 3 8 3 10 4 2006 9 5 8 5 10 6 2007 9 7 9 0 10 6 2008 10 6 9 7 11 5 2009 10 9 10 0 11 9 2010 11 3 10 4 12 3 2011 10 9 10 1 11 7 2012 11 1 10 3 11 9 2013 12 6 11 7 13 7 2014 11 8 11 0 12 6 2015 12 0 11 2 12 9 2016 13 2 12 2 14 2 Major changes to the survey methods in 2011 http www cdc gov SurveillancePractice reports brfss brfss html Indicates No Data Indicates Suppressed Data LL Lower Limit UL Upper Limit 68 UL 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 0

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