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DCH Community Health Needs Assessment

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DCH REGIONAL MEDICAL CENTER AND NORTHPORT MEDICAL CENTER 2019 COMMUNITY HEALTH NEEDS ASSESSMENT

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TABLE OF CONTENTS INTRODUCTION 2 EXECUTIVE SUMMARY 4 METHODOLOGY 7 OBTAINING PUBLIC INPUT 9 2016 CHNA Review 10 Stakeholder Input 13 Additional Healthcare Data 22 PRIORITIZED NEEDS AND ACTION PLANS TO ADDRESS 23 Risk Factors that Contribute to the Leading Causes of Death 24 Access to Care 25 Mental Health Substance and Alcohol Abuse 26 OTHER RECOGNIZED HEALTH CARE NEEDS 27 DOCUMENTING RESULTS PLANS TO MONITOR PROGRESS 28 RESOURCES AVAILABLE TO MEET THE IDENTIFIED NEEDS 29 Licensed Health Care Facilities Serving the Community 32 35 APPENDIX A County Health Profile Statistics 36 56 State of Alabama Medical Statistic Maps 57 61 APPENDIX B County Health Rankings and Roadmaps 62 THE BURDEN OF DIABETES IN ALABAMA 63 64

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INTRODUCTION DCH HEALTH SYSTEM As a local community owned not for profit organization the DCH Health System has been providing quality health care services for more than 95 years to citizens in West Alabama The DCH Health System operates three acute care hospitals including DCH Regional Medical Center a 583 licensed bed cornerstone hospital Northport Medical Center a 204 licensed bed community hospital and Fayette Medical Center a 61 licensed bed rural hospital Additionally DCH Health System operates the Lewis and Faye Manderson Cancer Center which is a certified member of the MD Anderson Cancer Network located on the campus at DCH Regional Medical Center Collectively these health care operational centers will be referred to hereinafter as the System The mission of the System is to improve the health of its community and to provide high quality compassionate care to all the residents of West Alabama regardless of their ability to pay The System serves residents in a seven county area that includes Tuscaloosa Bibb Fayette Green Hale Lamar and Pickens counties The hospitals within the System provide comprehensive inpatient and outpatient services surgery diagnostics and emergency services as well as specialty services to include pediatrics orthopedics cancer cardiology intensive care rehabilitation and psychiatry Each hospital within the System is accredited by the Joint Commission on Accreditation of Healthcare Organizations and the System hospitals have received numerous awards from independent agencies recognizing the high quality of services provided The System employs more than 4 700 people and more than 250 physicians practice at the hospitals within the System Many of the System s employees and physicians volunteer their time and expertise throughout the community in an effort to improve the health of the citizens within the community These dedicated 2 professionals work in the local schools malls churches and in civic organizations providing education and information The System sponsors health fairs and free prostate and breast screenings each year This report will reflect a joint Community Health Needs Assessment between DCH Regional Medical Center and Northport Medical Center The two hospitals are located within a few miles of each other and both hospitals provide a comprehensive array of services to residents in the seven county service area DCH Regional Medical Center and Northport Medical Center have received the Sole Community Hospital Designation requiring both hospitals to operate under a single Medicare provider number The regulations established under the Patient Protection and Affordable Care Act recognize and allow for collaboration under appropriate circumstances such as these DCH REGIONAL MEDICAL CENTER DCH Regional Medical Center is the largest hospital in the DCH System It is the most advanced trauma center in West Alabama and operates several specialty units including orthopedics cardiology pediatrics and cancer The Lewis and Faye Manderson Cancer Center is located on the campus of DCH Regional Medical Center and provides a full range of cancer treatment services with the most highly trained and experienced cancer specialists and physicians in the country in a state of the art building designed for an extraordinary patient experience In addition the Medical Center offers a wide range of comprehensive services including inpatient and outpatient services for pediatrics orthopedics oncology intensive

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care and cardiac care It also provides neonatal services physical and occupational therapy endoscopy general diagnostic services home health and a diabetes and nutrition education center DCH Regional Medical Center was also the first hospital in Alabama to provide Bloodless Medicine and Surgery which is a program that provides quality care without using blood transfusions In 2018 there were more than 22 000 patients admitted to the hospital over 77 000 emergency room visits and over 18 000 surgeries procedures performed The hospital provides clinical training for students in multiple health care fields and they have a Family Practice Residency Program with the University of Alabama The hospital is a major contributor in the community as it relates to health by providing many free services and education It is also one of the largest employers in the area NORTHPORT MEDICAL CENTER The System purchased Northport Medical Center in 1992 and it is also a community hospital that provides a broad spectrum of comprehensive inpatient and outpatient services and several specialty services The Women s Pavilion is a state of the art advanced obstetrical unit providing modern comfortable and well equipped rooms for mothers and their babies The hospital also has a neonatal intensive care unit with specialized physicians and staff At Northport Medical Center there is also a Rehabilitation Pavilion where patients can receive the most updated high quality care for orthopedic and neurological disorders North Harbor offers an inpatient treatment program for adults and geriatric individuals needing psychiatric care In 2018 there were more than 9 300 patients admitted to the hospital more than 53 000 emergency room visits and over 6 000 surgeries procedures performed EXECUTIVE SUMMARY The System assembled a collaborative team from DCH Regional Medical Center Northport Medical Center Hand Arendall Harrison Sale LLC SBC Consulting LLC and members of the identified community served by the System to conduct a Community Health Needs Assessment CHNA as required by the Affordable Care Act Section 501 r The team was tasked with identifying and prioritizing the issues of health within the community and developing an action plan to address those prioritized needs As noted in the introduction DCH Regional Medical Center and Northport Medical Center operate under the same Medicare provider number are located in close proximity to each other and serve the same or similar patient population therefore a joint CHNA was considered most appropriate A comprehensive and diverse 4 Stakeholder group was formed to review pertinent data and discuss what members of the group perceived to be important issues of health in the community The group included experts in public health government leaders representatives of the medically underserved low income and minorities as well as educators religious leaders law enforcement business leaders and representatives from both hospitals This assessment is a follow up to the System s 2016 CHNA and it defines the community served identifies the community s health issues includes appropriate and required input from individuals within the community and it prioritizes the needs with a plan to address those needs This report also includes pertinent support data from the Alabama Department of Public Health the Robert Woods Johnson Foundation the CDC the Alabama Rural Health Association the US Census Bureau and others

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Facilitating the assessment was the team of Hand Arendall Harrison Sale LLC and SBC Consulting LLC The facilitators worked closely with leadership from the DCH System to develop a Stakeholder Committee that represented the communities of both hospitals The Stakeholder Committee met as a group on April 12 2019 with 19 participants attending Additional telephone interviews and focus group meetings were held in May and June 2019 to gather review and consider additional input and data The Stakeholders considered the seven county geographic area served by the hospitals demographics disease states socio economic behavioral and physical factors as well as the low income minority and medically underserved populations in the area Public health and census data was provided to the group as was county specific information from the Robert Woods Johnson Foundation County Health Rankings and Roadmaps The data demonstrated that multiple counties in the seven county community service area ranked very poorly compared to other counties in Alabama in health outcomes quality of life health factors and health behaviors In order to be inclusive and diverse the Stakeholder Committee determined the community should be defined as the seven county area served by DCH Regional Medical Center and Northport Medical Center This is consistent with prior CHNAs conducted by the hospitals Most of the relevant counties were considered poor with lower education levels which studies indicate affect 5

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health in the community Other issues of health that were identified included the leading causes of death in the seven county area lack of dental mental and primary care professionals obesity diabetes hypertension access to care poverty the uninsured lack of resources outside of Tuscaloosa County sexually transmitted diseases gun violence transportation job training child care poor nutrition tuberculosis the opioid crisis and mental health Since the first CHNA was conducted in 2013 these health issues have consistently been identified as major issues of health in the community After meetings and interviews guided by the facilitator team coupled with an in depth review of pertinent data provided it was determined that the priorities of this CHNA should be Access to care Diabetes obesity and hypertension that contribute to the leading causes of death Mental health These issues were prioritized and the strategic plans to address them were determined based on their effectiveness and their financial feasibility The Stakeholder Committee and leadership from the hospitals also reviewed prior CHNAs and the established priorities as well as the ongoing plans currently in place to address those issues 6 For many years the System has focused on its mission to improve the health of its community and to engage and collaborate with other organizations in the community to promote a healthy lifestyle where community members live work play and worship Recognizing that changing human health behaviors is challenging the System has remained steadfast and determined to attempt to educate the general public in its service area to pursue improved health care attitudes and understandings that will have a positive impact on health care outcomes The System and its hospitals will always strive to provide excellent compassionate care for patients in the community without regard to race age or financial status This report will include the following A description of the methodology used to identify the health needs A review of the 2016 CHNA Prioritization of identified needs with strategic plans to address Supplemental data Existing resources available to assist in addressing the health needs Plans to monitor the approved CHNA to update if needed

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METHODOLOGY The System commissioned the assistance of Hand Arendall Harrison Sale LLC law firm in Birmingham Alabama and SBC Consulting LLC in Montgomery Alabama to aid in the process of conducting and completing the CHNA These two organizations have previously worked with the System in completing its two prior CHNAs conducted by the System The legal expertise of Hand Arendall Harrison Sale LLC and the healthcare consulting experience of SBC Consulting LLC ensured the System was compliant with the IRS CHNA regulations set forth in the Affordable Care Act In order to reflect the health needs of the entire community including the hospitals patient populations the System leadership and the facilitators developed a Stakeholder committee that represented the entire community including the medically underserved minorities and the lowincome It was important to include a broad spectrum of agencies community leaders and other community organization representatives to ensure a comprehensive and collaborative effort designed to identify needs prioritize those needs and develop a strategic longrange plan to address those needs Those who agreed to serve on the committee acknowledged the importance of owning the process working to strengthen the partnerships in the community and to be creative in developing a successful meaningful course of action that not only improved the health of the community but aimed to increase health equity within the community 7

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The Stakeholder Committee consisting of community members and representatives of the DCH System met on April 12 2019 The meeting began with a meal blessing from Pastor David Gay Sammy Watson Director of Community Relations for DCH Health System welcomed and thanked the group and stressed the importance of their participation in this exercise He then introduced consultant Stephanie Craft with SBC Consulting LLC Ms Craft discussed the purpose and reason for the CHNA and the major requirements of the CHNA Mrs Craft moderated a round table discussion among the Stakeholders The Committee s initial task was to define the System s service area The Committee considered the patient population of the hospitals special target populations disease states in the area demographics and other factors to assist in defining the Community It was the consensus of the group that the community should be defined as the entire seven county area the hospitals served which included the medically underserved minorities and low income populations A review of the 2013 and 2016 CHNAs were distributed and reviewed by the Committee The initial meeting was followed by small focus group meetings and phone interviews to further identify the issues of health and potential action plans Multiple sources of data including quantitative and qualitative data was provided and used to develop this assessment Data used was provided by the Alabama Department of Public Health the US Census Bureau the Robert Woods Johnson Foundation the CDC the Alabama Rural Health Association and internal data provided by the DCH Health System The Stakeholder Committee included the following Bryan Kindred CEO DCH Health System Sammy Watson DCH Director of Community Relations Brad Fisher DCH Corporate Director of Marketing and Communications Marsha White DCH Chief Nursing Officer and Vice President of Patient Care 8 Donal Conway MD DCH Emergency Department Physician Cynthia Burton Executive Director of Community Service Programs of West Alabama Chairman of the Board of Maude Whatley Health Services Stacy Adams Alabama Department of Public Health David Gay Interim Executive Director of Maude Whatley Health Services former employee of the Department of Mental Health pastor Amelia de los Reyes Director of Quality University of Alabama Student Health Center Ashley Adcox Area Agency on Aging Bishop Earnest Palmer Former Superintendent of Education retired pastor community leader Chris Holloway Tuscaloosa Fire and Rescue Donna Aaron Mayor of Northport retired school teacher Jim Harrison III DCH Board member community leader Lynn Armour Executive Director of the Good Samaritan Clinic Ron Abernathy Tuscaloosa County Sheriff Stan Acker County Commissioner University of Alabama System Finance Officer Anne Gaddy R N Manager of the DCH Diabetes and Nutrition Education Center Valerie Alford North Harbor Program Director Jennifer Singleton Community Education Manager of North Harbor Wendi Parminter DCH Director of Volunteer Services Doctoral student

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OBTAINING PUBLIC INPUT The regulations in Section 501 r 3 require input from three primary sources within the community DCH Regional Medical Center and Northport Medical Center acquired and documented input from 1 experts in public health 2 representatives of the medically underserved minorities and low income and 3 written comments received from the most recently conducted CHNA Although the report was made widely available to the public with a mechanism to make comments to date there have been no comments In addition input was received from a broad spectrum of individuals within the community to include law enforcement educators religious leaders city and county government officials other service agencies in the area and active community leaders Following approval of this report by the System s governing Board this report will be made widely available through the DCH Health System website for public access The following is a review of the input received 9

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1 2016 CHNA REVIEW Unemployment The 2016 CHNA identified needs prioritized needs and strategic plans to address those needs were presented to the Stakeholders for review To date no comments have been made on the System website in regards to this CHNA Many of the action plans are long term ongoing plans that will be restated in this 2019 CHNA Children in poverty The Community was defined as the seven county area served by DCH Regional Medical Center and Northport Medical Center Those counties include Tuscaloosa Bibb Lamar Pickens Fayette Hale and Green Identified issues of health in the 2016 CHNA were obtained from public input and national state and local data provided to the Stakeholder group Those needs identified included Wellness or lack thereof Obesity Diabetes Mental Health The seven county area s leading causes of death to include heart disease cancer stroke accidents and chronic lower respiratory disease Poor access to care Sexually transmitted diseases Gun violence Need for additional education on available services to the underserved and low income Transportation Job training Child care Nutrition Tuberculosis Physical inactivity and access to exercise opportunities Teen births Professional shortage areas in primary care mental health and dental care 10 The following three needs were considered priorities Action plans to address these issues were also developed 1 Obesity and unhealthy behaviors leading to diabetes and heart disease Actions to achieve included Increase the collaborative efforts with various partners in the seven county area to increase education for at risk individuals Increase the United Way 211 help line partners Partner with the Temporary Gardens program with the Druid City Garden Project to encourage and educate seniors as to how to grow their own healthy food Continue and expand the Golden Years program for seniors in the DCH System Continue the DCH and Northport outreach programs Start a wellness program for DCH employees through the Diabetes Education Center Expand social media and other local media outlets to educate on prevention and wellness 2 Access to Care Actions to achieve included Promote the use of telemedicine in the rural areas Create a formal partnership between the DCH Health System and Community Service Programs of West Alabama to increase referral sources and education on services provided Create a larger collaborative education effort among all service providers Assist with the funding of the Alternative Response Unit of the Tuscaloosa Fire and Rescue Unit

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3 Mental Health Actions to achieve included Explore funding of telepsychiatry in West Alabama Increase mental health awareness especially in the younger populations Continue to staff a North Harbor employee in the ED to encourage compliance with medications and follow up physician visits Encourage stronger partnerships with other providers in the area to ensure patients are getting appropriate treatment for mental health issues Recruit primary care physicians and behavioral clinicians on all levels at Northport Medical Center After completion of the CHNA in 2016 the System s Governing Board approved the CHNA process the prioritized needs and the action plans to address those needs The report was then made widely available to the public on the System website Since 2016 DCH Regional Medical Center and Northport Medical Center have accomplished the following action plans designed to improve the overall health in the seven county area defined as the Community Breast screenings including one specifically designed for the Latina community Diabetes education and home supplies Dialysis Food Gas cards and other transportation means Home medical equipment Temporary housing for loved ones receiving cancer treatment Mammograms Wound care supplies Assistance with utility payments Smoke detectors in homes Prosthesis Medications and specialty creams for cancer patients Weight scales Wigs for cancer patients Toiletries Home oxygen concentrators Many of the action plans overlap within each priority and some of the action plans are ongoing plans developed in the original CHNA They include Education in the area of diabetes hypertension mental health substance abuse suicide prevention and other issues of health among the seven county area to include health fairs school programs community forums and sponsorships of events within the area DCH Health System employee contributions to the DCH Foundation which provides grants that impact the community to include scholarships education and patient assistance These annual grants provide patient assistance to the community including Air transportation Blood pressure monitors Clothing Lymphedema supplies Collaboration and participation with other local agencies and providers to increase access and education especially in the rural areas Outreach program to educate physicians on the DCH Diabetes and Nutrition Education Center and the services provided Use of social media and other media outlets including radio shows in the Tuscaloosa market targeting the African American audience designed to educate listeners on various health related issues To date those include information on Prostate cancer Mental health Heart health Stroke 11

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DCH ED physician participating on a patient discharge committee to assist with the Alternative Response Unit of the Tuscaloosa Fire and Rescue who make appointments daily with frequent flyers that use 911 for minor non emergent situations such as mental health issues hypertension diabetes issues and other health issues that otherwise would result in a visit to the emergency rooms at DCH Regional Medical Center or Northport Medical Center DCH maintains a smoke free environment on the campus and encourages smoking cessation programs throughout the seven county area Continue the DCH Golden Years Program which is designed for individuals over the age of 50 This program includes A healthy eating education program A heart arrhythmia education program A fall prevention education program A Medicare prescription drug education program provided in conjunction with the Tuscaloosa Council on aging that identifies available drugs and those covered by Medicare This program provides education from physicians therapists nutritionists and other clinicians from DCH Regional Medical Center and Northport Medical Center There are more than 5 000 members in the programs to date Meetings are hosted at the hospitals with free refreshments and parking provided Continued employee contribution support of the United Way to allow for expansion of providers and services in the 2 1 1 Resource Guide which provides much needed access to education and guidance regarding multiple issues of health for residents throughout West Alabama Continued outreach to West Alabama residents for patients needing mental health services Education is provided throughout the region and collaborative efforts with other providers such as Maude Whatley Health Services Indian Rivers and the Good Samaritan Clinic are ongoing to ensure patients have access and appropriate treatment for the various mental health issues within the community DCH and Northport employees participation in the Tuscaloosa Mental Health Alliance which is a 501c3 charitable organization of more than 50 agencies businesses and groups that provide mental health services and resources to those in need in the community Northport Medical Center North Harbor sponsors the White Gala on the Black Warrior River which is a benefit that focuses on senior citizens Proceeds help provide transportation to medical appointments cancer treatments and dialysis provide hot lunches and assistance with home care Continued recruitment of physicians of multiple disciplines to address access to care in the entire community Since completion of the 2016 CHNA the System has recruited 25 physicians Those physicians include seven hospitalists three OB GYN physicians three general surgeons two anesthesiologists one orthopedist specializing in the hand one oncologist one nephrologist one pediatrician one trauma surgeon one family medicine physician and one emergency medicine physician DCH Regional Medical Center and Northport Medical Center are committed to improving the health of the citizens in the community through their ongoing dedication to address the most pressing health needs identified through their Community Health Needs Assessment 2 STAKEHOLDER INPUT A Government Health Department Input As required by the Affordable Care Act DCH Regional Medical Center and Northport Medical Center enlisted Stacey Adams the District Administrator of the Alabama Department of Public Health s West Central District of Alabama Ms Adams input provided essential insight to the many issues of health in west Alabama She attended the initial meeting on March 28 2019 and participated in the discussion on several issues of health in the community including mental health and the contributing behavioral factors that result in the leading causes of death in the area Services provided by the Tuscaloosa Department of Public Health include but are not limited to clinical services 13

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such as ALL Kids comprehensive dental care for children in the Alabama Medicaid program Women Infants and Children WIC program an overall women s health program nutrition counseling tuberculosis testing immunizations sexually transmitted disease testing treatment and counseling The area office also provides the SMARTS Program which offers sexually transmitted disease infection prevention and pregnancy prevention information and services to high risk youth between the ages of 13 and 19 in areas of west Alabama In addition the area office provides many environmental services Ms Adams indicated through her work in the area that chronic diseases and prevention of these diseases diabetes and mental health were major issues of health in her area She also noted that getting appropriate and timely care for these issues was difficult for many in the area due to major transportation issues not only in the rural areas outside of Tuscaloosa County but within the city of Tuscaloosa as well She stated that the public transportation system was ineffective and underused For example she said patients needing dialysis in the rural areas could potentially spend hours on a bus trying to get to a scheduled appointment for dialysis treatment and because of that many simply did not make their appointments She offered the suggestion of a mobile unit that could go directly to patients at their homes for treatment of certain conditions She said funding was an obstacle to this suggestion As it relates to diabetes data provided through the Alabama Department of Public Health showed diabetes is a leading contributor to the leading causes of death in the community which include heart disease and stroke The data showed that in several counties of the community more than 12 5 of all adults have diabetes and in one of the counties of the community the rate was 23 Alabama leads the nation in diabetes The state obesity map in Appendix A shows approximately 35 of the population in the seven county community are obese and type 2 diabetes can be a direct result of obesity In 2012 the Alabama Department of Public Health Tuscaloosa County Diabetes Coalition 14 was established to increase awareness prevent the development of diabetes and to better manage patients who are diagnosed with diabetes The DCH Diabetes and Nutrition Education Center partners alongside the Tuscaloosa County Health Department and other agencies in the area to provide crucial information and education in the form of flyers health fairs social media and visits to doctors offices to ensure residents in the community have the information and resources to minimize the effects of diabetes and decrease the diabetes epidemic in the community The opioid epidemic in the area was discussed as one of the issues of health for the community According to the CDC Alabama has the highest prescribing rate of opioids in the country It was discussed among the Stakeholders that access to Narcon Naloxone the drug used to prevent overdose deaths from opioids needs to be made more easily accessible throughout the community Ms Adams said the State Health Officer has a standing order that Narcan can be purchased directly from pharmacies A list of those participating pharmacies needs to be made available to the public to increase access to this life saving drug B Medically Underserved Low Income and Minority Input To satisfy an additional requirement DCH Regional Medical Center and Northport Medical Center obtained and documented input from those individuals or groups representing the medically underserved low income and minority populations As reported earlier in this report the community was defined as the seven county service area of both hospitals to ensure inclusion of these vulnerable groups Those individuals who provided valuable input and expertise in working with these groups included Cynthia Burton Executive Director of Community Service Programs of West Alabama Chairman of Maude Whatley Bishop Earnest Palmer retired pastor former Superintendent of Education

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David Gay Interim Director of Maude Whatley Health Services a retired leader in the Department of Mental Health and a local pastor Lynn Armour Executive Director of the Good Samaritan Clinic Each of these organizations provides comprehensive services to the underserved uninsured and minority populations in west Alabama DCH Regional Medical Center and Northport Medical Center work closely with each of these organizations to ensure patients are getting better overall access to care appropriate care and the necessary education and information to improve overall healthcare within this at risk group Each of these individuals attended the initial CHNA meeting In the meeting Ms Burton expressed great concern regarding access to care in the rural communities outside of Tuscaloosa She stated that many rural hospitals were closing further decreasing access to care She pointed out that expansion of Medicaid was critical for those in the rural area because poverty was so prevalent in the areas outside of Tuscaloosa She also stated that lack of access to primary care often resulted in visits to the emergency departments of both hospitals for care Bishop Palmer spoke to the issue of mental health stating there were many mental health issues among children but because there was such a stigma associated with mental health many children were undiagnosed and failed to receive the proper treatment further complicating the problem To assure there was adequate information gathered from these valuable resources a small focus group meeting was held on Friday April 12th in Tuscaloosa Attending the meeting were David Gay Lynn Armour Cynthia Burton Sammy Watson from the DCH System and Stephanie Craft one of the CHNA facilitators A more comprehensive discussion from these valuable resources further identified issues in the community Mr David Gay described his background of more than 30 years as a mental health worker in Bryce Hospital and Taylor Hardin Secure Medical Facility He is currently the CEO of Maude Whatley Health Services which provides a full complement of healthrelated services to include pediatric and adolescent medicine dental care mental health services chiropractic services a full service pharmacy laboratory services nutrition health promotion and disease prevention outreach programs HIV AIDS primary care services family and internal medicine and women s healthcare services Mr Gay identified access to care for the medically underserved low income and minority population as a concern especially in the rural areas He said that in his opinion there were not enough providers in the rural areas to treat patients therefore they typically ended up in the emergency room at both hospitals for care He also said patients were unaware of the services provided by these organizations that serve these groups In an attempt to address this issue Maude Whatley provides a staff member in the DCH Regional Medical Center emergency room to educate patients as to the services provided by Maude Whatley in hopes that they will return for follow up in a more appropriate setting He plans to continue this service He has also observed the steady increase in the Hispanic population in the area Through his experience working with this vulnerable population it was his opinion that the Hispanic population was reluctant to seek care because of language barriers and communication issues He indicated there was a need for additional education and information in areas where these groups work play and worship Mr Gay also pointed out that because of the lack of access to care many mental health patients were not receiving appropriate care often resulting in arrests and time in jail or emergency room visits He stressed the need for a more proactive instead of a reactive approach by increasing education and information on prevention especially in the rural areas to decrease the number of emergency room visits Lynn Armour is the Executive Director of the Good Samaritan Clinic which is the only source of free primary healthcare and dental care for residents of West Alabama Ms Armour stated that the most common health issues seen by her organization were diabetes hypertension obesity and depression She indicated that patients needed education on healthy 17

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eating and how and when to take their medications Non compliance with taking medications often resulted in chronic problems and visits to the emergency department She pointed out that the Good Samaritan Clinic is staffed with volunteers and as such the clinic is open only three days a week She also said many patients were simply unaware of the services provided by the clinic therefore an increase in education to those vulnerable patients was necessary Staff of the Good Samaritan Clinic recently began working with the DCH System hospitals by providing a social worker at discharge in the emergency room to educate patients on their services They are also providing telemedicine to patients for follow up visits because transportation to the clinic is a major barrier to access their care Many patients rely on others to take them to follow up appointments or they simply have no transportation to get there The local library has donated space for the set up of equipment that is used in telemedicine As long as patients have access to a mobile phone they can participate Cynthia Burton is the Executive Director of Community Services Programs of West Alabama Her non profit organization provides multiple services to low income and vulnerable populations with the goal of creating family self sufficiency and improved quality of life The organization provides educational programs for children designed to reach their full potential They include Early Intervention Early Head Start and Head Start programs They also provide housing assistance so that families can have safe adequate and affordable housing Their support services include utility assistance food assistance meals on wheels workforce development life skills training and emergency aid Ms Burton pointed out that patients in rural areas come to the hospitals emergency departments for care because they do not have insurance or access to primary care and said that until there were additional primary care providers in the rural areas patients would continue to come to the hospital for their primary care She also has observed the rapid increase in the Hispanic population She noted that typically they have no insurance and because of that they do not seek regular primary care To complicate matters 18 she also alluded to the language barrier issue facing this community Ms Burton said there was a need for education to residents in rural west Alabama as to what constituted a true emergency and she stated that expansion of Medicaid was critical in solving the access to care issue Ms Burton s organization is opening a Hispanic resource center in Tuscaloosa to assist with that vulnerable population by providing information on resources in west Alabama that provide health care She suggested and encouraged the use of social media and notifications on phones and tablets to increase access to information She also suggested public service announcements on radio and television and assistance from DCH and Northport by providing an advisor to speak to various church groups and organizations in the area She encouraged a stronger partnership between DCH Regional Medical Center and Northport Medical Center by assisting with education through the Saving Life Initiative Tuscaloosa Ministerial Alliance and The Watch Group Bishop Palmer who was not in attendance sent word that he would strongly encourage participation from the DCH or Northport leadership in Leadership Tuscaloosa C Additional Stakeholder Input In addition to the information gathered at the initial meeting several other meetings were held to gain additional data and input from Stakeholders Information gathered from these additional Stakeholders allowed the facilitators and the hospitals to get a complete picture of the health of the community The information was comprehensive and representative of the entire community These additional Stakeholders included representatives of law enforcement education other local agencies the medical community and government officials A summary of the information discussed is submitted below In the initial CHNA meeting several community representatives discussed the major issues of health in the community

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Amelia de los Reyes Director of Quality University of Alabama Student Health Center Ms de los Reyes made a brief presentation to the group of her organization s CHNA conducted by her doctoral peers and herself She identified the following issues of health Perception among many in the community that wealthy people get better health care service than those who are less fortunate Parents views on immunization for their children Inability by the low income population to access healthy food leading to poor nutrition and obesity Mental health depression and the stigma attached to it Lack of psychologist follow up with mental health patients following the closing of Bryce and Partlow mental hospitals 65 of people in the Tuscaloosa County Jail have mental illness there is a lack of a place for them to receive appropriate treatment Many risk factors in certain areas of the community include drug use lack of family planning the increase of sexually transmitted diseases domestic violence Access to healthcare and no insurance coverage Homeless population Language barriers Need for a community resource list The issues of health identified by Ms de los Reyes mirrored those issues identified by others in the Stakeholder group Bryan Kindred CEO DCH System Mr Kindred identified the opioid epidemic as not only a nationwide issue but a local community health issue as well He noted that Tuscaloosa has the highest opioid prescribing rate in the country He mentioned that a diverse community group is investigating the possibility of starting a local non profit program housed in a non hospital based stand alone facility supported by other major organizations in the area 19

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designed to address the immediate needs of those affected by homelessness and substance abuse in a more appropriate caring environment to prevent an admission to the emergency room or an arrest Mr Kindred and others in the community visited a similar program implemented in San Antonio Texas for additional details called the Haven for Hope Donal Conway MD DCH Regional Medical Center emergency room physician Dr Conway added to the opioid crisis discussion by stating that Alabama as a state has the highest prescribing rate in the country and has for a few years He also noted that Governor Kay Ivey established the Alabama Opioid and Addiction Council in August of 2017 to develop recommendations and action plans to address the opioid crisis in Alabama This is an ongoing plan with long range objectives to address the opioid crisis He also noted the Alabama Department of Public Health has a prescription drug monitoring program which is used as a method to prevent patient doctor shopping and physician overprescribing of these drugs Although Dr Conway agreed that the opioid crisis was indeed a major issue of health it was his opinion that the biggest killers in west Alabama were coronary artery disease and cancer He believed the CHNA should prioritize the prevention of these diseases including a smoking cessation program education on good nutrition to cut down on obesity controlling hypertension through medication management and compliance and management of diabetes through a more healthy lifestyle Finally Dr Conway identified mental health as a major issue of health He suggested the need for additional resources community education programs and a more coordinated partnership with mental health providers in the area He also pointed out that funding for additional personnel and equipment was a major barrier to improving the mental health issue in the community Ron Abernathy Sheriff of Tuscaloosa County Mr Abernathy echoed the sentiment of many on the Stakeholder panel by discussing the opioid crisis and the problem with access to care for mental 20 health patients As it relates to Narcon the drug that reverses opioid overdoses he said that his department has sufficient access to Narcon and it was easy to administer with training but it has a fast expiration date He suggested that if the public had easier access to this drug many of the overdoses they see could be avoided As an example of easier access he pointed out that in the past only paramedics had access to Stop Bleed Kits in an active shooter situation but now it is available to the general public From the mental health perspective Sheriff Abernathy said that although the Probate Judge has increased the number of mental health officers they are not medical professionals Most mental health patients have problems because they do not take their medications or they are not being properly managed by a physician Because of this many become homeless end up in the emergency room or jail He indicated approximately 250 of the 600 individuals in jail are there for mental health problems and they do not belong there They should be in treatment facilities Finally he pointed out that although there is a big law enforcement presence in the area it is very hard to access the rural areas because of the size of Tuscaloosa County Traffic and construction issues within the city are problems as is adequate staff needed to effectively serve the outlying areas Mr Abernathy discussed a project in San Antonio Texas The Haven for Hope Project which is a non profit collaboration between several community organizations in the area with the mission of providing services to the homeless community He suggested the possibility of a similar project in Tuscaloosa as a long range plan that would provide services for mental health patients those with alcohol and substance abuse issues and the homeless in the area Stan Acker County Commissioner Mr Acker agreed with the health issue of access to care in the rural area which was putting a major strain on the available resources in the city of Tuscaloosa He stated that Tuscaloosa County was one of a very few in the nation that cross trained their employees to be

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both deputies and paramedics He said there was a need for more of these cross trained individuals because they could deliver emergency care in the rural areas in lieu of sending an entire fire crew as a first responder Chris Holloway EMS Chief Tuscaloosa Fire and Rescue Mr Holloway discussed the Tuscaloosa Fire and Rescue Department s ACTION program Appropriate Care and Treatment in Our Neighborhood The ACTION program is a coordinated partnership with the University of Alabama that provides a behavioral unit and a nurse practitioner unit staffed with appropriate personnel who offer at the scene care to patients who frequently call 911 for their medical needs These patients typically have low level emergency conditions that can be easily treated without the need for a trip to the emergency room for primary care situations Most of these patients have chronic conditions including medication issues hypertension depression and other non emergent conditions Mr Holloway said that due to the lack of personnel and equipment needed it was virtually impossible to provide their services to those in the rural areas where there is a great need He pointed out that they must have additional mid level providers and other necessary equipment if they are to provide services in the rural areas but funding is a major obstacle The Tuscaloosa Fire Rescue s behavioral unit sees approximately 10 patients a day who need mental health evaluations but paramedics are not trained to perform mental health evaluations therefore the only option is to take these patients to Northport Hospital or jail Mr Holloway said that unfortunately the Tuscaloosa County jail is the largest mental health institution in the area He suggested the development of a task force to develop a system to respond to mental health patients and appropriately care for them without sending them to the hospitals or to jail Mr Holloway indicated the ACTION program needed better exposure better access to patients and additional resources to save healthcare dollars and eliminate some of the overcrowding in the emergency department In order to help with these issues Dr Conway said that the DCH Regional Medical Center emergency department is now identifying patients who are at high risk of re admissions They are identified on discharge and Tuscaloosa Fire and Rescue schedules follow up visits to check on their progress and ensure medications are refilled in a timely manner Mr Holloway suggested the community paramedicine model is a more cost effective and efficient way to provide care in the rural areas and this model is gaining notoriety throughout the state Other Stakeholders in the initial meeting agreed that mental health the leading causes of death and the factors that contribute to those causes of death were certainly priorities that need to be addressed Access to care was also considered a major issue On June 4 2019 facilitator Stephanie Craft met with Valerie Alford the Program Director of North Harbor at Northport Hospital and Jennifer Singleton the Community Education Manager at North Harbor Both ladies stated mental health was a problem in the entire west Alabama community Barriers to mental health care included a lack of inpatient beds an insufficient number of mental health professionals and other necessary resources needed to treat these patients Ms Alford and Ms Singleton identified transportation as a major barrier as well The lack of transportation for patients to attend mental health follow up visits often creates a medication compliance issue Many of the mental health patients need monthly anti psychotic shots to manage their mental health problems however more often than not they have no transportation to get their shots These patients then end up in the emergency room and all gains that were previously made in the process of treating their disease are lost They noted better access to medication is needed Ms Alford and Ms Singleton also identified suicide as an issue of health among children and adults North Harbor does not take patients under the age of 18 so there is a lack of access to mental healthcare for those under 18 Ms Alford was gathering information on local volunteer 21

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programs designed to help at risk teenagers Also North Harbor is part of the Tuscaloosa Mental Health Alliance which is a group of area agencies healthcare providers businesses and community leaders that work together to identify problem areas within the mental health arena and find solutions to those problems Through fundraising activities the Alliance provides grant money to the members and associated agencies that allows for assistance with acute treatment needs as well as programs and education materials that can benefit those affected by mental health The Alliance has just published a book on bullying which will be provided to students in one or two schools in the area Their hope is to get it into more and more schools in west Alabama In addition Ms Singleton is receiving training in the Talks Save Lives program from the American Foundation for Suicide Prevention Once she is trained she will be able to go into the school systems and provide presentations on suicide prevention types of diabetes Type 1 which is mostly hereditary and Type 2 which is often caused from obesity She indicated that many people do not know they have diabetes and as such can die from complications associated with the disease In several of the counties in the community diabetes was one of the top five leading causes of death Ms Gaddy said that many diabetic patients do not take their medications properly they have poor nutritional habits and they fail to show up for physician visits She also said that many residents in the seven county area are not aware of the Diabetes and Nutrition Education Center She and her staff work tirelessly to educate physicians and residents of the services they provide The Center boasts very positive results with patients who are compliant The Center provides services to residents in all seven counties in the community as well as children who have been court ordered to receive nutrition counseling She discussed barriers in the rural areas such as transportation Finally Ms Alford and Ms Singleton said the homeless population in Tuscaloosa is growing Currently there are three tent cities in the area and approximately 95 of the people living there are mentally ill There are also approximately 400 school children in Tuscaloosa County alone that are homeless Ms Alford suggested North Harbor provide on site services to those mental health patients in these tent cities maybe one day a week to deliver anti psychotic shots to those people in need She also suggested the development of a threeperson team to include a nurse practitioner a social worker and possibly someone from law enforcement to volunteer their time to assist with the homeless population Thirty percent of scheduled patients are no shows She sees the need to get additional information out through the use of social media or a possible marketing campaign One of the action plans from the 2016 CHNA was to start a wellness program for employees of the DCH System for those on the System insurance plan This program was implemented Employees receive meters and supplies help with their medication and diabetes self management training in a classroom setting at three month intervals There are no co pays for strips So far the programs are very successful for those who participate It is not a mandatory program Ms Gaddy plans to continue and expand the program On June 18 2019 facilitator Stephanie Craft interviewed Anne Gaddy R N who is the Director of the DCH Diabetes and Nutrition Education Center The Center provides education and training in selfmanagement know how for people with diabetes or those who are at risk for developing the disease Ms Gaddy confirmed that diabetes is a major issue of health in the seven county area served by the hospitals Diabetes data provided to the Stakeholder group also supported the growing incidence of this disease in the community Alabama leads the nation in diabetes cases Ms Gaddy referred to the two 22 3 ADDITIONAL HEALTHCARE DATA Refer to Appendix A and B Data was obtained from public input and from pertinent national state and local data Appendix A includes pertinent data from the Alabama Department of Public Health and Appendix B includes data from the Robert Woods Johnson Foundation County Rankings and Roadmaps

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PRIORITIZED NEEDS AND ACTION PLANS TO ADDRESS 23

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Following a substantial review of the Stakeholders identified issues of health and the available quantitative data the Stakeholders and the leadership of DCH Regional Medical Center and Northport Medical Center determined three issues of health needed to be prioritized This decision was based on the available resources the potential effectiveness and the financial feasibility Prior assessments and priorities were also considered as many of the action plans are long term The final intent was to build on the existing plan to improve the lives of the citizens in the community and enhance the quality of healthcare for the community The following needs were established as priorities 1 Risk Factors Such as Hypertension Diabetes and Obesity that Result in the Leading Causes of Death Actions to Achieve Continue employee contributions to the DCH Foundation which provides in house grants for outreach programs for the entire community Those programs include free screenings and health fairs including screenings for the Hispanic population in the community the DCH Diabetes and Nutrition Education Center 24 the Help and Hope Cancer Fund gas cards and means of transportation for families utility payment assistance clothing home medical equipment and other services Expand and upgrade the DCH System employee diabetes education program by adding coverage on the System s health insurance plan to allow for Medical Nutrition Therapy which is evidenced based nutrition practice It allows for individually tailored nutrition plans and studies show it is much more effective than the diabetes self management training which is currently covered on the health insurance plan for the System employees Continue to market the DCH Diabetes and Nutrition Education Center Plans include continuing free health fairs a minimum of three per year and providing flyers and additional Diabetes Center materials in areas where those in the community live work play and worship including churches assisted living facilities nursing homes schools and businesses Plans also include a continuing effort to educate physicians on

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the benefits of the Center to increase referrals and to continue collaborative efforts between other providers in the area such as Maude Whatley and the Good Samaritan Clinic to ensure the medically underserved and lowincome groups are getting the education and care they need There are also plans to increase awareness through a local marketing campaign and through the use of an existing contract with local radio stations owned by Town Square Media To date there have been four segments aired with six segments still to be aired The plan is to renew the contract as the segments have reached a large audience especially in the African American audience throughout the seven county area Volunteer staff of DCH Regional Medical Center and Northport Medical Center to speak at churches schools civic clubs and other community events to increase awareness of obesity diabetes and unhealthy behaviors that contribute to the leading causes of death Review resources grant opportunities and community success stories from the US Department of Health and Human Services Healthy People 2020 and 2030 to determine which successful programs could be implemented in the seven county community of DCH Regional Medical Center and Northport Medical Center Determination of any program implementation will depend on potential effectiveness and financial feasibility An example would be the Healthy Family Healthy Heart program created by the National Heart Lung and Blood Institute at the National Institutes of Health This program could be implemented in a teaching environment open to the public at the hospitals Renew radio health segments with the local radio stations that educate listeners on various health related issues Continue partnerships with other local providers and organizations to educate at risk individuals in the community DCH plans to continue their financial support of the United Way and the programs they provide as well as sponsorships of annual benefits that provide much needed services in the community 2 Access to Care Actions to Achieve The DCH System will continue and expand clinics both primary care and specialty clinics at weekly or monthly intervals in the rural areas identified as part of the community Since the 2016 CHNA was completed the DCH System has recruited 25 healthcare providers to include hospitalists a pediatrician orthopedists obstetrics and gynecologists anesthesiologists general surgeons a trauma critical care surgeon a nephrologist cardiologists and a family physician and emergency medicine physician These efforts will continue to ensure greater access to care in the community Continue to explore the use of telemedicine at DCH Regional Medical Center and Northport Medical Center The hospitals will continue to financially support other local providers such as the Good Samaritan Clinic and Maude Whatley Health Services who currently provide these services to the medically underserved and the low income and minority groups Continue partnerships with other local providers including Community Services Programs of West Alabama Maude Whatley Health Services The United Way and The Good Samaritan Clinic to ensure residents in the seven county area are informed and educated on the services provided by these organizations including transportation child care meals resource information and other valuable services Maude Whatley Health Services will continue staffing a case worker in the emergency room of DCH Regional Medical Center to increase follow up care and medication compliance DCH Regional Medical Center and Northport Medical Center will explore funding of and clinical volunteer participation for the Alternate Response Unit of the Tuscaloosa Fire and Rescue to allow for additional equipment and staff so that there is improved access in the rural communities Currently the ARU is limited to Tuscaloosa County due to lack of funding equipment and staff DCH Regional Medical 25

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Center and Northport Medical Center subject to HIPPA regulations and participant consent desire to implement a community awareness plan to identify preventable and repeat visits to the emergency room and appropriately share that information with the Tuscaloosa Fire and Rescue so that Tuscaloosa Fire and Rescue can make follow up appointments to directly communicate with citizens to assist and educate the patients and care givers on methods to better manage the chronic conditions that often contribute to these costly and preventable trips to the System s emergency rooms 3 Mental Health Substance and Alcohol Abuse Actions to Achieve Continue to recruit behavioral clinicians to the area as the seven county area is considered to be a mental health professional shortage area Continue support of other mental health providers in the area including Maude Whatley Health Services Indian Rivers Mental Health Center and other outpatient community mental health centers Continued support of and participation in the Tuscaloosa Mental Health Alliance which is an organization of more than 50 healthcare providers businesses local clinicians agencies and concerned citizens who together are working to identify gaps in mental health services to provide education and crisis intervention when needed and to improve the quality of life of those impaired by mental health issues North Harbor located at Northport Medical Center is exploring providing on site services one day a week to provide much needed anti psychotic shots to the growing population of homeless people in the area Many of the homeless in the area are mental health patients who do not have access to the antipsychotic shot that is necessary to manage their mental health conditions 26 North Harbor will continue to participate in the federal government s SBIRT program which is a screening intervention and referral to treatment program for individuals with substance abuse issues or who may be at risk for developing these issues North Harbor plans allow for its Director of Community Education to be trained in the Talks Saves Lives program which will allow her to go out in the school systems and speak about the prevention of suicide North Harbor will continue to provide monetary support and boots on the ground advocacy in the community to educate on mental health issues and the resources available in the community to address those issues The DCH System is exploring a potential project The Village Center Project at Tuscaloosa which would be a collaborative effort with various community organizations to provide much needed services to the homeless those with substance abuse issues and those with mental health issues Members of System leadership have visited San Antonio Texas to see a similar program in that area This proposed plan will provide a venue for the homeless and those affected by mental health and substance abuse to get appropriate treatment instead of going to the emergency room or jail Continue exploring the opportunity for telepsychiatry in west Alabama Consideration of a marketing campaign using social media and other media outlets to reduce the stigma of abuse and to motivate opioid users to seek help Establish a community volunteer mentoring program for at risk teens

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OTHER RECOGNIZED HEALTH CARE NEEDS 27

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While other needs were identified by the Stakeholder committee input and national state and local data provided it was deemed most appropriate to continue progress already made in the identified priorities Many of the additional needs identified can be and are addressed through programs provided by other state agencies and organizations in Alabama It should be noted that the DCH System was instrumental in providing substantial funding and resources to build the Safe Center of Tuscaloosa The President and CEO of the DCH System is a member of the Board of Directors The Safe Center is a collaborative community agency that provides a free standing center for victims of sexual assault There is no charge for the services provided Although it is in its infancy it is successfully providing a compassionate patient centered environment for treatment and forensic evaluation of sexual assault victims In addition during the past three years members of the leadership of the DCH System team have been Board members of the following entities The Good Samaritan Clinic Hospice of West Alabama Indian Rivers Mental Health Center Turning Point center for abused women Presbyterian Apartments provides a safe and low cost place for seniors Area Agency on Aging Advisory Board Easter Seals of West Alabama Police Athletic League designed to keep kids off the streets Boy Scouts Black Warrior Council character building organization Participation in these important organizations ensures the DCH System has a vested interest in improving the quality of life and health status of the community it serves DOCUMENTING RESULTS PLANS TO MONITOR PROGRESS Upon approval of this report by the DCH System Governing Board of Directors the DCH System will make the report widely available to the public on the System website There is a mechanism in place that allows comments from the public The DCH System will diligently make every effort to implement the action plans reported in this assessment in a timely manner with the continual 28 goal of improving the health status of the members of the seven county community decreasing health inequity in the community and improving the quality of life for all citizens in the community including the medically underserved the low income and the minority populations in west Alabama

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RESOURCES AVAILABLE TO MEET THE IDENTIFIED NEEDS 29

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In its effort to consider and evaluate the extent to which the needs of the medically underserved population were adequately considered the CHNA Committee undertook to evaluate the public resources currently available in the hospital s service area Many of these resources are specifically reviewed and discussed herein above in this report Other resources noted to be available in the service area included the following Alabama Cooperative Extension Services Alabama Department of Human Resources Alabama Department of Mental Health Alabama Department of Public Health Alabama Department of Senior Services Alabama Head Injury Foundation Serves those disabled by brain or spinal cord injuries Alabama Medicaid American Red Cross Disaster relief services to military CPR First Aid Safety Classes Alabama Rural Health Association The Arc of Tuscaloosa Job skills training and placement for adults age 21 and older Area Agency on Aging of West Alabama assists with needs and provides services for the elderly Community Service Programs of West Alabama Community agency dedicated to improve the quality of life for low income and vulnerable populations Easter Seals West Alabama Provides assistance to children and adults with physical handicaps Family Counseling Services Counseling for individuals and families FOCUS on Senior Citizens Programs and services for senior citizens Girl Scouts of North Central Alabama Educational and recreational programs for girls Good Samaritan Clinic Provides primary health care to the uninsured with incomes at or below 185 of the federal poverty guidelines Health InfoNet of Alabama Consumer health information service provided by the Alabama public and medical libraries Hospice of West Alabama Health care support for the terminally ill either inpatient or at home care 211 Information and Referral Services Linking those needing help or information with those who can provide it Arts n Autism Provides autism services to children from preschool to young adults Maude Whatley Health Center Provides primary healthcare services to the medically underserved residents of West Alabama Big Brothers Big Sisters Screened volunteers provide one on one friendship to at risk children Phoenix House Halfway house for drug and alcohol dependent men and women Boy Scouts of America Black Warrior Council Citizenship fitness and leadership opportunities for young men Police Athletic League of Tuscaloosa juvenile crime prevention program Boys Girls Club of West Alabama Education recreation and leadership programs for children and youth Bradford Health Services Chemical dependency treatment programs Caring Days Adult Day Care Day care for adults with Alzheimer s Parkinson s and other forms of dementia 30 Child Abuse Prevention Services Addresses prevention and self help Safe Center of Tuscaloosa free standing forensics center for victims of sexual assault Salvation Army Emergency food and lodging for those with nowhere to turn Success by Six Prepares at risk four year olds for kindergarten The Sickle Cell Disease Association of America West Alabama Chapter Improves health status

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Temporary Emergency Services Help to those in need including food clothing and emergency medicine Turning Point Safe shelter and counseling for abuse victims and their children Tuscaloosa Mental Health Alliance mental health services support and outreach Tuscaloosa s One Place Providing support services to families and help developing skills and resources to improve the family s quality of life United Cerebral Palsy of West Alabama Serving individuals with intellectual and physical disabilities and their families United Way of West Alabama University of Alabama Community Service Center Student advocacy program for the community West Alabama AIDS Outreach HIV AIDS education and services to those living with HIV AIDS YMCA of Tuscaloosa Co and Benjamin Barnes YMCA of Tuscaloosa Co Downtown Youth adult and family athletics community education and clubs The hospital s healthcare consultants also identified several other licensed healthcare facilities that present opportunities for hospital shared community needs programs in the future including but not limited to those shown in the health care facility charts on pages 32 35 31

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY 32 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 Cahaba Medical Care PC Fayette Assisted Living Facility Morningside of Fayette Community Mental Health Center Northwest Alabama Mental Health Center End Stage Renal Disease Treatment Ctr Fayette Dialysis Home Health Agency Fayette Medical Center HomeCare Hospital Fayette Medical Center Independent Clinical Laboratory Fayette Medical Center Laboratory Nursing Home Fayette Med Ctr Long Term Care Unit Rural Health Clinic Fayette Medical Center Greene End Stage Renal Disease Treatment Ctr 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 Hlth Ctr 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 Ctr Pickens County Dialysis Federally Qualified Health Center Aliceville Family Practice Home Health Agencies Amedisys Home Health of Reform Encompass Health Home Health Hospital Pickens County Medical Center Inc Independent Clinical Laboratory Pickens County Medical Center Lab Nursing Homes Aliceville Manor Nursing Home Arbor Woods Health and Rehab Carrollton Primary Care Rural Health Clinic 33

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY Cont County Type of Facility Facility Tuscaloosa Abortion or Reproductive Health Ctr West Alabama Women s Center Inc Ambulatory Surgical Centers North River Surgical Center Tuscaloosa Endoscopy Center Tuscaloosa Surgical Center Assisted Living Facilities Brookdale Northport ALF Crimson Village Daffodil House Assisted Living LLC Hallmark Manor Hamrick Highlands Assisted Living Heritage Residential Care Village Bldg 2 Martinview Assisted Living West Morning Pointe of Tuscaloosa North River Village LLC Pine Valley Retirement Community Woodlands at Tannehill Assisted Living Facilities Specialty Care Brookdale Northport SCALF Martinview Assisted Living East Morning Pointe of Tuscaloosa Specialty Remembrance Village The Tides at Crimson Village Traditions Way 34 Community Mental Health Centers Crisis Stabilization Unit Medical Health Services Inc Pathway Training Center Indian Rivers Phillips Treatment Center End State Renal Disease Treatment Ctrs Northport Dialysis RRC Northridge Tuscaloosa Dialysis Crimson Dialysis Tuscaloosa University Dialysis Federally Qualified Health Centers West Tuscaloosa Health Center Crescent East Health Care Whatley Health Services Inc Home Health Agencies Amedisys Home Health of Tuscaloosa DCH Home Health Care Agency Tuscaloosa County Home Care

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LICENSED HEALTH CARE FACILITIES SERVING THE COMMUNITY Cont County Type of Facility Facility Tuscaloosa Hospices Alabama Hospice Care of Tuscaloosa Amedisys Hospice of Tuscaloosa Comfort Care Hospice of Tuscaloosa Encompass Health Hospice Northport Hospice of West Alabama Hospice of West Alabama Inc Homecare SouthernCare New Beacon 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 Art Fertility Program of Alabama Choices Pregnancy Clinic DCH Regional Medical Center Laboratory Maude L Whatley Health Center Neptune Diagnostics Northport Medical Center Laboratory Quest Diagnostics Tuscaloosa The Radiology Clinic Southern Blood Services Talecris Plasma Resources Inc University Medical Center Laboratory Independent Physiological Labs Clinic for Rheumatic Disease Sav A Life of Tuscaloosa Inc 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 Rehabilitation Centers Tuscaloosa Rehabilitation Hand Center Inc Brewer Porch Children s Center Champion Sport Medicine Rehab Center Restore Therapy Services Outpatient Snow Sleep Center P C Sleep Disorder Center 35

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APPENDIX A SU M M ARY Total Population 206 102 Births 2 589 Deaths 1 762 Median Age 32 6 Life Expectancy at Birth 75 8 Total Fertility Rate per 1 000 Females Aged 10 49 1 499 0 Number Marriages TUSCALOOSA 2016 HEALTH PROFILE 1 154 Rate 5 6 Number Divorces 110 Rate 0 5 Rates per 1 000 population PR E GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 3 776 75 4 304 20 8 Births 2 589 12 6 197 13 5 Induced Terminations of Pregnancy 608 12 1 61 4 2 Estimated Total Fetal Losses 579 46 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 2 589 4 42 151 2 392 Rate 0 7 7 8 42 1 51 3 White 1 451 0 10 61 1 380 Rate 0 0 2 9 26 8 47 7 All Births Black and Other 1 138 4 32 90 1 012 1 7 16 3 68 6 57 2 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 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Number Percent Number Percent 1 226 47 4 184 93 4 305 11 8 32 16 2 96 3 7 7 3 6 1 244 48 1 164 83 2 Percentages are of all births with known status for females in specified age group 36 Females Aged 10 19

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APPENDIX A TUSCALOOSA 2016 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 33 12 21 5 0 5 12 7 8 3 18 5 25 4 0 0 39 7 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 11 4 7 2 0 2 4 2 2 8 6 2 10 2 0 0 15 9 22 8 14 3 0 3 8 5 5 5 12 3 15 2 0 0 23 8 Neonatal Deaths Rate per 1 000 Births Infant deaths are by race of child births are by race of mother 2 0 1 6 E STIMATE D POPU L AT I O N S B Y AGE GR O U P RAC E AN D SE X All Races Age Group White Black and Other Total Male Female Total Male Female Total Male Female 206 102 99 273 106 829 134 158 66 328 67 830 71 944 32 945 38 999 0 4 12 408 6 305 6 103 7 179 3 658 3 521 5 229 2 647 2 582 5 9 11 905 6 010 5 895 6 757 3 346 3 411 5 148 2 664 2 484 10 14 11 611 5 944 5 667 6 709 3 462 3 247 4 902 2 482 2 420 15 44 97 806 47 729 50 077 62 253 31 541 30 712 35 553 16 188 19 365 45 64 46 900 22 387 24 513 31 946 15 827 16 119 14 954 6 560 8 394 65 84 22 499 9 957 12 542 16 995 7 738 9 257 5 504 2 219 3 285 2 973 941 2 032 2 319 756 1 563 654 185 469 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 1 762 878 884 1 269 659 610 493 219 274 8 5 8 8 8 3 9 5 9 9 9 0 6 9 6 6 7 0 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 Heart Disease 461 223 7 230 231 7 231 Cancer 323 156 7 165 166 2 158 83 40 3 34 34 2 Stroke Accidents Black and Other Number Rate Number Rate 216 2 333 248 2 128 177 9 147 9 231 172 2 92 127 9 49 45 9 59 44 0 24 33 4 95 46 1 60 60 4 35 32 8 72 53 7 23 32 0 124 60 2 52 52 4 72 67 4 106 79 0 18 25 0 Diabetes 35 17 0 22 22 2 13 12 2 21 15 7 14 19 5 Influenza and Pneumonia 50 24 3 18 18 1 32 30 0 36 26 8 14 19 5 Alzheimer s Disease 79 38 3 31 31 2 48 44 9 73 54 4 6 8 3 Suicide 24 11 6 20 20 1 4 3 7 21 15 7 3 4 2 Homicide 16 7 8 14 14 1 2 1 9 6 4 5 10 13 9 2 1 0 2 2 0 0 0 0 0 0 0 2 2 8 CLRD HIV Disease Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 37

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APPENDIX A TUSCALOOSA 2016 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 Total Rate Age Group All Accidents 95 46 1 8 14 9 Total Motor Vehicle 47 22 8 7 13 0 0 14 Suffocation Poisoning Smoke Fire and Flames Number Rate 1 762 8 5 39 1 1 3 1 5 1 1 9 15 44 142 1 5 32 15 5 0 0 0 45 64 396 8 4 0 0 0 0 0 0 65 84 744 33 1 85 441 148 3 Falls 3 1 5 0 0 0 Drowning 2 1 0 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 8 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 All Cancers Male Female Number Rate Number Rate Number Rate 323 156 7 165 166 2 158 147 9 Trachea Bronchus Lung Pleura 93 45 1 52 52 4 41 38 4 Colorectal 32 15 5 13 13 1 19 17 8 Breast female 22 10 7 0 0 0 22 20 6 Prostate male 22 10 7 22 22 2 0 0 0 Pancreas 24 11 6 13 13 1 11 10 3 Leukemias Non Hodgkin s Lymphomas Ovary female Brain and Other Nervous System Stomach Uterus and Cervix female Esophagus Melanoma of Skin Other 5 2 4 3 3 0 2 1 9 10 4 9 7 7 1 3 2 8 5 2 4 0 0 0 5 4 7 12 5 8 6 6 0 6 5 5 7 3 4 5 5 0 2 1 9 14 6 8 0 0 0 14 13 1 2 1 0 2 2 0 0 0 0 6 2 9 4 4 0 2 1 9 69 38 31 Rates are per 100 000 population in specified categories Measurements 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 aged 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 38

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APPENDIX A SU M M ARY Total Population 20 324 Births 231 Deaths 250 Median Age 41 9 Life Expectancy at Birth 73 5 Total Fertility Rate per 1 000 Females Aged 10 49 1 911 5 Marriages PICKENS 2016 HEALTH PROFILE Number 96 Rate 4 7 Number Divorces 77 Rate 3 8 Rates per 1 000 population PREGN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 315 87 9 23 20 0 Births 231 11 4 17 14 8 Induced Terminations of Pregnancy 34 9 5 2 1 7 Estimated Total Fetal Losses 50 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 BY AGE GRO U P O F M O T HE R Total 10 14 15 17 18 19 20 231 0 9 8 214 Rate 0 0 25 9 34 5 55 3 White 130 0 6 3 121 Rate 0 0 37 3 28 0 58 7 All Births Black and Other 101 0 3 5 93 0 0 16 1 40 2 51 4 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 Females Aged 10 19 Number Percent Number Percent 125 54 1 17 100 0 Low Weight Births 33 14 3 2 11 8 Multiple Births 11 4 8 0 0 0 134 58 0 14 82 4 Births to Unmarried Women Medicaid Births Percentages are of all births with known status for females in specified age group 39

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APPENDIX A PICKENS 2016 HEALTH PROFILE Cont INFA NT RE LATE D M ORTAL 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 7 6 1 0 0 0 30 3 46 2 9 9 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths 1 0 1 0 0 0 4 3 0 0 9 9 0 0 0 0 0 0 6 6 0 0 0 0 26 0 46 2 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 6 E STIMATE D PO PU 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 20 324 10 156 10 168 11 788 6 119 5 669 8 536 4 037 4 499 0 4 1 062 561 501 514 287 227 548 274 274 5 9 1 091 541 550 560 282 278 531 259 272 10 14 1 126 614 512 574 312 262 552 302 250 15 44 7 591 4 008 3 583 4 105 2 273 1 832 3 486 1 735 1 751 45 64 5 764 2 792 2 972 3 487 1 798 1 689 2 277 994 1 283 65 84 3 272 1 489 1 783 2 255 1 051 1 204 1 017 438 579 418 151 267 293 116 177 125 35 90 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 250 116 134 154 76 78 96 40 56 12 3 11 4 13 2 13 1 12 4 13 8 11 2 9 9 12 4 SEL E 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 65 319 8 31 305 2 34 334 4 34 288 4 31 363 2 Cancer 46 226 3 24 236 3 22 216 4 28 237 5 18 210 9 Stroke 9 44 3 3 29 5 6 59 0 7 59 4 2 23 4 Accidents 16 78 7 11 108 3 5 49 2 8 67 9 8 93 7 CLRD 21 103 3 12 118 2 9 88 5 16 135 7 5 58 6 Diabetes 4 19 7 2 19 7 2 19 7 1 8 5 3 35 1 Influenza and Pneumonia 10 49 2 3 29 5 7 68 8 9 76 3 1 11 7 Alzheimer s Disease 10 49 2 2 19 7 8 78 7 9 76 3 1 11 7 Suicide 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Homicide 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 HIV Disease 1 4 9 1 9 8 0 0 0 0 0 0 1 11 7 Rates are per 100 000 population in specified categories CLRD is known as Chronic Lower Respiratory Disease 40 Black and Other

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PICKENS 2016 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages Number D E AT HS B Y AGE GRO U P Ages 19 and Under Rate Number Total Rate Age Group All Accidents 16 78 7 2 44 2 Total Motor Vehicle 11 54 1 2 44 2 0 14 Number Rate 250 12 3 9 2 7 Suffocation 0 0 0 0 0 0 15 44 11 1 4 Poisoning 3 14 8 0 0 0 45 64 53 9 2 Smoke Fire and Flames 0 0 0 0 0 0 65 84 107 32 7 85 70 167 5 Falls 1 4 9 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 CTE D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate All Cancers 46 226 3 24 236 3 22 216 4 Trachea Bronchus Lung Pleura 17 83 6 12 118 2 5 49 2 Colorectal 3 14 8 2 19 7 1 9 8 Breast female 1 4 9 0 0 0 1 9 8 Prostate male 2 9 8 2 19 7 0 0 0 Pancreas 8 39 4 4 39 4 4 39 3 Leukemias 0 0 0 0 0 0 0 0 0 Non Hodgkin s Lymphomas 3 14 8 0 0 0 3 29 5 Ovary female 0 0 0 0 0 0 0 0 0 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 1 4 9 0 0 0 1 9 8 Uterus and Cervix female 1 4 9 0 0 0 1 9 8 Esophagus 0 0 0 0 0 0 0 0 0 Melanoma of Skin 0 9 8 1 9 8 1 9 8 Other 8 3 5 Rates are per 100 000 population in specified categories Measurements 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 aged 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 41

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APPENDIX A SU M M ARY Total Population 13 918 Births 133 Deaths 204 Median Age 44 4 Life Expectancy at Birth 73 3 Total Fertility Rate per 1 000 Females Aged 10 49 1 772 0 Marriages LAMAR 2016 HEALTH PROFILE Number 57 Rate 4 1 Number Divorces 73 Rate 5 2 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 164 69 4 20 23 6 Births 133 9 6 17 20 1 4 1 7 0 0 0 27 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 All Births Total 10 14 15 17 18 19 20 133 0 8 9 116 Rate 0 0 32 9 55 6 49 2 White 119 0 8 7 104 Rate 0 0 39 7 52 1 51 2 Black and Other Rate 14 0 0 2 12 0 0 0 0 72 5 36 7 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 Percent Number Percent 53 39 8 11 64 7 Low Weight Births 15 11 3 0 0 0 Multiple Births 10 7 5 0 0 0 Medicaid Births 67 50 4 11 64 7 Percentages are of all births with known status for females in specified age group 42 Females Aged 10 19 Number

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LAMAR 2016 HEALTH PROFILE Cont APPENDIX A INFA NT RE LATE D MORTA LI 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 1 0 0 0 0 7 5 8 4 0 0 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 7 5 8 4 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 6 E STIM ATE D POPU 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 13 918 6 782 7 136 12 155 5 958 6 197 1 763 824 939 0 4 696 357 339 575 291 284 121 66 55 5 9 820 422 398 706 359 347 114 63 51 10 14 883 447 436 773 394 379 110 53 57 15 44 4 676 2 312 2 364 4 050 2 008 2 042 626 304 322 45 64 3 886 1 946 1 940 3 373 1 716 1 657 513 230 283 65 84 2 657 1 209 1 448 2 417 1 112 1 305 240 97 143 300 89 211 261 78 183 39 11 28 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 204 115 89 182 103 79 22 12 10 14 7 17 0 12 5 15 0 17 3 12 7 12 5 14 6 10 6 SE LE CT 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 55 395 2 32 471 8 23 322 3 48 394 9 7 397 1 Cancer 42 301 8 27 398 1 15 210 2 38 312 6 4 226 9 Stroke 11 79 0 6 88 5 5 70 1 10 82 3 1 56 7 Accidents 12 86 2 11 162 2 1 14 0 11 90 5 1 56 7 CLRD 17 122 1 8 118 0 9 126 1 17 139 9 0 0 0 Diabetes 7 50 3 5 73 7 2 28 0 5 41 1 2 113 4 Influenza and Pneumonia 3 21 6 1 14 7 2 28 0 3 24 7 0 0 0 Alzheimer s Disease 6 43 1 2 29 5 4 56 1 6 49 4 0 0 0 Suicide 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Homicide 1 7 2 1 14 7 0 0 0 1 8 2 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 43

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APPENDIX A LAMAR 2016 HEALTH PROFILE Cont A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GR O U P Ages 19 and Under Total Number Rate Number Rate 12 86 2 0 0 0 Total All Accidents Age Group Number Rate 204 14 7 Motor Vehicle 5 35 9 0 0 0 0 14 1 0 4 Suffocation 0 0 0 0 0 0 15 44 13 2 8 Poisoning 0 0 0 0 0 0 45 64 42 10 8 111 41 8 37 123 3 Smoke Fire and Flames 1 7 2 0 0 0 65 84 Falls 2 14 4 0 0 0 85 Drowning 1 7 2 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 LEC 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 42 301 8 27 398 1 15 210 2 Trachea Bronchus Lung Pleura 13 93 4 9 132 7 4 56 1 Colorectal 4 28 7 2 29 5 2 28 0 Breast female 3 21 6 0 0 0 3 42 0 Prostate male 2 14 4 2 29 5 0 0 0 Pancreas 3 21 6 3 44 2 0 0 0 Leukemias 1 7 2 1 14 7 0 0 0 Non Hodgkin s Lymphomas 1 7 2 1 14 7 0 0 0 Ovary female 2 14 4 0 0 0 2 28 0 Brain and Other Nervous System 1 7 2 1 14 7 0 0 0 Stomach 3 21 6 2 29 5 1 14 0 Uterus and Cervix female 2 14 4 0 0 0 2 28 0 Esophagus 1 7 2 1 14 7 0 0 0 Melanoma of Skin 1 7 2 1 14 7 0 0 0 Other 5 4 1 Rates are per 100 000 population in specified categories Measurements 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 aged 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 44

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APPENDIX A SU M M ARY Total Population 14 952 Births 182 Deaths 189 Median Age 40 4 Life Expectancy at Birth 74 9 Total Fertility Rate per 1 000 Females Aged 10 49 1 944 5 Marriages HALE 2016 HEALTH PROFILE Number 82 Rate 5 5 Number Divorces 25 Rate 1 7 Rates per 1 000 population PREGN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 257 91 7 26 25 7 Births 182 12 2 15 14 9 Induced Terminations of Pregnancy 35 12 5 7 6 9 Estimated Total Fetal Losses 40 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 BY AGE GRO U P O F M O T HE R Total 10 14 15 17 18 19 20 182 0 4 11 167 Rate 0 0 12 7 52 3 60 4 White 67 0 0 4 63 Rate 0 0 0 0 59 2 64 5 All Births Black and Other 115 0 4 7 104 0 0 18 7 49 0 58 2 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 Births to Unmarried Women Low Weight Births Multiple Births Medicaid Births Females Aged 10 19 Number Percent Number Percent 122 67 0 13 86 7 26 14 3 3 20 0 6 3 3 0 0 0 121 66 5 14 93 3 Percentages are of all births with known status for females in specified age group 45

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APPENDIX A HALE 2016 HEALTH PROFILE Cont INFA NT RE LATE D M ORTAL 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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 6 E STIMATE D PO PU 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 14 952 7 060 7 892 6 133 3 049 3 084 8 819 4 011 4 808 0 4 1 044 536 508 382 205 177 662 331 331 5 9 924 481 443 361 183 178 563 298 265 10 14 928 466 462 333 171 162 595 295 300 15 44 5 308 2 504 2 804 1 885 954 931 3 423 1 550 1 873 45 64 3 979 1 846 2 133 1 694 859 835 2 285 987 1 298 65 84 2 410 1 120 1 290 1 295 618 677 1 115 502 613 359 107 252 183 59 124 176 48 128 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 189 103 86 84 44 40 105 59 46 12 6 14 6 10 9 13 7 14 4 13 0 11 9 14 7 9 6 SEL E 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 57 381 2 38 538 2 19 240 8 24 391 3 33 374 2 Cancer 40 267 5 22 311 6 18 228 1 13 212 0 27 306 2 Stroke 13 86 9 6 85 0 7 88 7 5 81 5 8 90 7 Accidents 8 53 5 6 85 0 2 25 3 4 65 2 4 45 4 CLRD 6 40 1 4 56 7 2 25 3 6 97 8 0 0 0 Diabetes 4 26 8 1 14 2 3 38 0 1 16 3 3 34 0 Influenza and Pneumonia 1 6 7 1 14 2 0 0 0 0 0 0 1 11 3 Alzheimer s Disease 5 33 4 2 28 3 3 38 0 4 65 2 1 11 3 Suicide 2 13 4 2 28 3 0 0 0 1 16 3 1 11 3 Homicide 3 20 1 2 28 3 1 12 7 1 16 3 2 22 7 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 46 Black and Other

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HALE 2016 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GR O U P Ages 19 and Under Total Number Rate Number Rate Age Group All Accidents 8 53 5 0 0 0 Total Motor Vehicle 6 40 1 0 0 0 0 14 Number Rate 189 12 6 1 0 3 Suffocation 0 0 0 0 0 0 15 44 12 2 3 Poisoning 0 0 0 0 0 0 45 64 49 12 3 Smoke Fire and Flames 0 0 0 0 0 0 65 84 92 38 2 Falls 1 6 7 0 0 0 85 35 97 5 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 CTED C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate All Cancers 40 267 5 22 311 6 18 228 1 Trachea Bronchus Lung Pleura 14 93 6 8 113 3 6 76 0 Colorectal 5 33 4 3 42 5 2 25 3 Breast female 3 20 1 0 0 0 3 38 0 Prostate male 2 13 4 2 28 3 0 0 0 Pancreas 2 13 4 1 14 2 1 12 7 Leukemias 2 13 4 1 14 2 1 12 7 Non Hodgkin s Lymphomas 0 0 0 0 0 0 0 0 0 Ovary female 0 0 0 0 0 0 0 0 0 Brain and Other Nervous System 0 0 0 0 0 0 0 0 0 Stomach 1 6 7 1 14 2 0 0 0 Uterus and Cervix female 3 20 1 0 0 0 3 38 0 Esophagus 1 6 7 1 14 2 0 0 0 Melanoma of Skin 0 0 0 0 0 0 0 0 0 Other 7 5 2 Rates are per 100 000 population in specified categories Measurements 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 aged 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 47

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APPENDIX A SU M M ARY Total Population 8 422 Births 101 Deaths 104 Median Age 42 3 Life Expectancy at Birth 75 5 Total Fertility Rate per 1 000 Females Aged 10 49 2 082 0 Marriages GREENE 2016 HEALTH PROFILE Number 40 Rate 4 7 Number Divorces 4 Rate 0 5 Rates per 1 000 population PR E GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 150 106 8 18 34 5 Births 101 12 0 12 23 0 Induced Terminations of Pregnancy 26 18 5 3 5 8 Estimated Total Fetal Losses 23 3 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTHS B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 101 1 1 10 89 Rate 3 7 6 6 99 2 62 3 White 11 0 0 1 10 Rate 0 0 0 0 138 9 53 8 All Births Black and Other Rate 90 1 1 9 79 4 4 7 1 96 2 63 6 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 76 75 2 10 83 3 Low Weight Births 17 16 8 2 16 7 6 5 9 0 0 0 75 74 3 12 100 0 Multiple Births Medicaid Births Percentages are of all births with known status for females in specified age group 48 Females Aged 10 19

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GREENE 2016 HEALTH PROFILE Cont APPENDIX A INFA NT RE LATE D MORTA LI 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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 6 E STIM ATE D POPU 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 8 422 4 001 4 421 1 528 756 772 6 894 3 245 3 649 0 4 498 242 256 63 32 31 435 210 225 5 9 547 272 275 51 26 25 496 246 250 10 14 543 285 258 63 38 25 480 247 233 15 44 2 851 1 446 1 405 379 198 181 2 472 1 248 1 224 45 64 2 344 1 055 1 289 510 249 261 1 834 806 1 028 65 84 1 392 624 768 393 189 204 999 435 564 247 77 170 69 24 45 178 53 125 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 104 50 54 22 10 12 82 40 42 12 3 12 5 12 2 14 4 13 2 15 5 11 9 12 3 11 5 SE LE CT 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 31 368 1 17 424 9 14 316 7 7 458 1 24 348 1 Cancer 18 213 7 6 150 0 12 271 4 3 196 3 15 217 6 Stroke 2 23 7 0 0 0 2 45 2 0 0 0 2 29 0 Accidents 4 47 5 4 100 0 0 0 0 0 0 0 4 58 0 CLRD 4 47 5 1 25 0 3 67 9 1 65 4 3 43 5 Diabetes 3 35 6 1 25 0 2 45 2 2 130 9 1 14 5 Influenza and Pneumonia 5 59 4 1 25 0 4 90 5 1 65 4 4 58 0 Alzheimer s Disease 6 71 2 3 75 0 3 67 9 3 196 3 3 43 5 Suicide 2 23 7 2 50 0 0 0 0 0 0 0 2 29 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 49

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GREENE 2016 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GR O U P Ages 19 and Under Total Number Rate Number Rate 4 47 5 0 0 0 Total All Accidents Age Group Number Rate 104 12 3 Motor Vehicle 3 35 6 0 0 0 0 14 0 0 0 Suffocation 0 0 0 0 0 0 15 44 9 3 2 Poisoning 0 0 0 0 0 0 45 64 24 10 2 Smoke Fire and Flames 0 0 0 0 0 0 65 84 40 28 7 Falls 0 0 0 0 0 0 85 31 125 5 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 L E 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 18 213 7 6 150 0 12 271 4 Trachea Bronchus Lung Pleura 3 35 6 2 50 0 1 22 6 Colorectal 1 11 9 0 0 0 1 22 6 Breast female 4 47 5 0 0 0 4 90 5 Prostate male 3 35 6 3 75 0 0 0 0 Pancreas 0 0 0 0 0 0 0 0 0 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 11 9 0 0 0 1 22 6 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 0 0 0 0 0 0 0 0 0 Esophagus 1 11 9 0 0 0 1 22 6 Melanoma of Skin 0 0 0 0 0 0 0 0 0 Other 5 1 4 All Cancers Rates are per 100 000 population in specified categories Measurements 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 aged 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 50

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APPENDIX A SU M M ARY Total Population 16 546 Births 159 Deaths 249 Median Age 43 7 Life Expectancy at Birth 73 9 Total Fertility Rate per 1 000 Females Aged 10 49 1 755 0 Marriages FAYETTE 2016 HEALTH PROFILE Number 98 Rate 5 9 Number Divorces 13 Rate 0 8 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 206 74 3 13 13 4 Births 159 9 6 11 11 4 Induced Terminations of Pregnancy 14 5 1 0 0 0 Estimated Total Fetal Losses 33 2 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 BY AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 159 0 3 8 148 Rate 0 0 10 9 43 8 51 0 White 128 0 1 8 119 Rate 0 0 4 3 51 3 48 1 All Births Black and Other Rate 31 0 2 0 29 0 0 49 8 0 0 67 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 Females Aged 10 19 Number Percent Number Percent Births to Unmarried Women 62 39 2 10 90 9 Low Weight Births 14 8 8 2 18 2 4 2 5 0 0 0 86 54 1 8 72 7 Multiple Births Medicaid Births Percentages are of all births with known status for females in specified age group 51

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APPENDIX A FAYETTE 2016 HEALTH PROFILE Cont INFA NT RE LATE D M ORTAL 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 6 3 0 0 32 3 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths Rate per 1 000 Births 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 6 3 0 0 32 3 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 6 E STIMATE D PO PU 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 16 546 8 179 8 367 14 258 7 045 7 213 2 288 1 134 1 154 0 4 918 458 460 736 366 370 182 92 90 5 9 952 528 424 795 443 352 157 85 72 10 14 986 505 481 840 427 413 146 78 68 15 44 5 662 2 890 2 772 4 887 2 479 2 408 775 411 364 45 64 4 615 2 274 2 341 3 992 1 967 2 025 623 307 316 65 84 3 083 1 398 1 685 2 728 1 250 1 478 355 148 207 330 126 204 280 113 167 50 13 37 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 249 135 114 224 116 108 25 19 6 15 0 16 5 13 6 15 7 16 5 15 0 10 9 16 8 5 2 SEL E 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 60 362 6 34 415 7 26 310 7 58 406 8 2 87 4 Cancer 61 368 7 33 403 5 28 334 6 53 371 7 8 349 7 Stroke 11 66 5 7 85 6 4 47 8 10 70 1 1 43 7 8 48 4 6 73 4 2 23 9 7 49 1 1 43 7 19 114 8 8 97 8 113 131 5 18 126 2 1 43 7 Diabetes 4 24 2 3 36 7 1 12 0 3 21 0 1 43 7 Influenza and Pneumonia 5 30 2 1 12 2 4 47 8 5 35 1 0 0 0 Accidents CLRD Alzheimer s Disease 15 90 7 7 85 6 8 95 6 14 98 2 1 43 7 Suicide 6 36 3 5 61 1 1 12 0 5 35 1 1 43 7 Homicide 1 6 0 1 12 2 0 0 0 0 0 0 1 43 7 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 52 Black and Other

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FAYETTE 2016 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GRO U P Ages 19 and Under Total Number Rate Number Rate 8 48 4 0 0 0 Total Motor Vehicle 3 18 1 0 0 0 0 14 Suffocation 0 0 0 0 0 0 15 44 Poisoning 2 12 1 0 0 0 Smoke Fire and Flames 1 6 0 0 0 0 85 All Accidents Falls 1 6 0 0 0 0 Drowning 0 0 0 0 0 0 Firearms 0 0 0 0 0 0 Other Accidents 1 0 Age Group Number Rate 249 15 0 1 0 4 11 1 9 45 64 49 10 6 65 84 132 42 8 56 169 7 Rates are per 1 000 population in specified age group Rates are per 100 000 population in specified categories SE LE CTE D C AN C E R SI T E D E AT HS Total Male Female Number Rate Number Rate Number Rate All Cancers 61 368 7 33 403 5 28 334 6 Trachea Bronchus Lung Pleura 16 96 7 9 110 0 7 83 7 Colorectal 6 36 3 5 61 1 1 12 0 Breast female 5 30 2 0 0 0 5 59 8 Prostate male 3 18 1 3 36 7 0 0 0 Pancreas 5 30 2 3 36 7 2 23 9 Leukemias 4 24 2 4 48 9 0 0 0 Non Hodgkin s Lymphomas 2 12 1 1 12 2 1 12 0 Ovary female 2 12 1 0 0 0 2 23 9 Brain and Other Nervous System 1 6 0 0 0 0 1 12 0 Stomach 1 6 0 0 0 0 1 12 0 Uterus and Cervix female 1 6 0 0 0 0 1 12 0 Esophagus 2 12 1 0 0 0 2 23 9 0 0 0 0 0 0 0 0 0 13 8 5 Melanoma of Skin Other Rates are per 100 000 population in specified categories Measurements 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 aged 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 53

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APPENDIX A SU M M ARY Total Population 22 643 Births 273 Deaths 239 Median Age 39 6 Life Expectancy at Birth 74 1 Total Fertility Rate per 1 000 Females Aged 10 49 2 164 5 Number Marriages BIBB 2016 HEALTH PROFILE 147 Rate 6 5 Number Divorces 0 Rate 0 0 Rates per 1 000 population PR E GN AN C Y N ATAL I T Y Females Aged 15 44 Females Aged 10 19 Number Rate Number Rate Estimated Pregnancies 344 90 5 31 26 2 Births 273 12 1 25 21 2 Induced Terminations of Pregnancy 15 3 9 1 0 8 Estimated Total Fetal Losses 56 5 Birth rates per 1 000 population Estimated pregnancy and induced termination of pregnancy rates are per 1 000 females in specified age group BIRTHS B Y AGE GR O U P O F M O T HE R Total 10 14 15 17 18 19 20 273 0 6 19 248 Rate 0 0 16 9 80 1 61 5 White 212 0 6 17 189 Rate 0 0 21 5 91 2 59 7 All Births Black and Other Rate 61 0 0 2 59 0 0 0 0 39 4 68 2 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 129 47 3 21 84 0 Low Weight Births 26 9 5 2 8 0 Multiple Births 20 7 3 0 0 0 149 54 8 21 84 0 Births to Unmarried Women Medicaid Births Percentages are of all births with known status for females in specified age group 54 Females Aged 10 19

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APPENDIX A BIBB 2016 HEALTH PROFILE Cont INFA NT RE LATE D MORTA LI 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 1 4 0 0 0 18 3 4 7 65 6 0 0 0 0 0 0 Infant Deaths Rate per 1 000 Births Postneonatal Deaths 1 0 1 0 0 0 3 7 0 0 16 4 0 0 0 0 0 0 4 1 3 0 0 0 14 7 4 7 49 2 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 6 E STIM ATE D POPU 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 22 643 12 145 10 498 17 334 8 873 8 461 5 309 3 272 2 037 0 4 1 274 642 632 948 469 479 326 173 153 5 9 1 256 650 606 985 510 475 271 140 131 10 14 1 296 700 596 1 041 5718 470 255 129 126 15 44 9 145 5 345 3 800 6 493 3 474 3 019 2 652 1 871 781 45 64 6 178 3 242 2 936 4 870 2 508 2 362 1 308 734 574 65 84 3 172 1 465 1 707 2 740 1 254 1 486 432 211 221 322 101 221 257 87 170 65 14 51 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 239 139 100 203 114 89 36 25 11 10 6 11 5 9 5 11 7 12 8 10 5 6 8 7 6 5 4 SE LE CT 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 63 278 2 38 312 9 25 238 1 52 300 0 11 207 2 Cancer 55 242 9 33 271 7 22 209 6 48 276 9 7 131 9 Stroke 15 66 2 8 65 9 7 66 7 15 86 5 0 0 0 Accidents 26 114 8 15 123 5 11 104 8 20 115 4 6 113 0 CLRD 13 57 4 8 65 9 5 47 6 12 69 2 1 18 8 Diabetes 2 8 8 1 8 2 1 9 5 2 11 5 0 0 0 Influenza and Pneumonia 8 35 3 8 65 9 0 0 0 7 40 4 1 18 8 Alzheimer s Disease 7 30 9 1 8 2 6 57 2 7 40 4 0 0 0 Suicide 4 17 7 3 24 7 1 9 5 4 23 1 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 55

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BIBB 2016 HEALTH PROFILE Cont APPENDIX A A CCIDE NTA L DE ATH S All Ages D E AT HS B Y AGE GR O U P Ages 19 and Under Number Rate All Accidents 26 114 8 Motor Vehicle 10 44 2 Number Total Rate Age Group 2 38 9 Total 1 19 5 0 14 Number Rate 239 10 6 5 1 3 Suffocation 1 4 4 0 0 0 15 44 20 2 2 Poisoning 7 30 9 0 0 0 45 64 56 9 1 Smoke Fire and Flames 0 0 0 0 0 0 65 84 117 36 9 85 41 127 3 Falls 4 17 7 0 0 0 Drowning 1 4 4 1 19 5 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 55 242 9 33 271 7 22 209 6 Trachea Bronchus Lung Pleura 13 57 4 8 65 9 5 47 6 Colorectal 7 30 9 6 49 4 1 9 5 Breast female 3 13 2 0 0 0 3 28 6 Prostate male 2 8 8 2 16 5 0 0 0 Pancreas 1 4 4 1 8 2 0 0 0 Leukemias 3 13 2 3 24 7 0 0 0 Non Hodgkin s Lymphomas 2 8 8 1 8 2 1 9 5 Ovary female 4 17 7 0 0 0 4 38 1 Brain and Other Nervous System 3 13 2 2 16 5 1 9 5 Stomach 2 8 8 1 8 2 1 9 5 Uterus and Cervix female 0 0 0 0 0 0 0 0 0 Esophagus 1 4 4 1 8 2 0 0 0 0 0 0 0 0 0 0 0 0 14 8 6 Melanoma of Skin Other Rates are per 100 000 population in specified categories Measurements 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 aged 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 56

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STATE OF ALABAMA MEDICAL STATISTIC MAPS APPENDIX A Percent of Obese Alabamians 2016 Public Health Areas 30 6 Lauderdale Limestone Jackson Madison Colbert 35 3 Lawrence Franklin Marion Morgan Winston Dekalb Marshall 36 5 Cherokee Cullman Etowah Blount Walker Lamar Calhoun St Clair Fayette 34 8 Talladega Tuscaloosa Pickens Bibb Coosa Tallapoosa Chilton Hale Perry Autauga Sumter Randolph Clay Shelby Greene 42 3 36 3 Cleburne Jefferson 38 3 Chambers Lee Elmore Macon Dallas Marengo Russell Montgomery Lowndes Choctaw 34 4 Bullock Wilcox Barbour Clarke 33 1 Crenshaw Monroe Washington Pike Butler Conecuh Coffee Covington Escambia Geneva Dale Henry 42 1 Houston Mobile 40 Baldwin 57

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STATE OF ALABAMA MEDICAL STATISTIC MAPS Cont APPENDIX A Medically Underserved Areas Populations MUA Ps Lauderdale Limestone Jackson Madison Colbert Lawrence Franklin Marion Morgan Winston Dekalb Marshall Cherokee Cullman Etowah Blount Walker Lamar Calhoun St Clair Fayette Jefferson Cleburne Talladega Pickens Tuscaloosa Bibb Greene Coosa Tallapoosa Chilton Hale Perry Autauga Sumter Randolph Clay Shelby Chambers Lee Elmore Macon Dallas Marengo Russell Montgomery Lowndes Choctaw Bullock Wilcox Barbour Clarke Crenshaw Monroe Washington Pike Butler Conecuh Dale Coffee Covington Escambia Geneva Henry Houston Mobile Baldwin 58 Legend Not Designated Medically Underserved Area Medically Underserved Population Medically Underserved Area and Population

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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 59

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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 Macon 17 16 Lowndes Choctaw 18 Lee 17 Montgomery 20 19 18 Washington Barbour 17 Pike Butler 18 Monroe 17 17 20 Clarke Russell Bullock 16 Wilcox 18 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 Dale 17 17 Henry 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 60

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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 Danita Crear 334 206 2925 or Danita Crear adph state al us 61

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APPENDIX B C O UNT Y H E ALTH RA N KIN G S ROA DMA PS C O MPAR E COUN TIES 2018 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 23 37 41 66 54 15 52 31 22 53 63 35 9 40 9 600 10 300 9 700 11 700 14 000 10 600 8 400 10 700 27 46 25 67 60 38 51 21 20 25 20 34 27 21 25 4 4 4 6 4 9 4 4 5 6 5 2 4 5 5 0 4 6 4 6 5 0 4 3 5 3 5 0 4 7 4 8 10 10 10 11 15 14 11 13 Health Factors 27 33 37 64 59 11 46 Health Behaviors 34 30 39 65 59 22 42 Adult Smoking 22 20 21 20 24 22 20 21 Adult Obesity 35 36 34 38 42 41 33 35 5 6 7 7 7 6 7 6 3 0 6 0 6 9 6 8 Food Environment Index Physical Inactivity 29 37 34 38 32 34 28 29 Access to Exercise Opportunities 63 46 18 49 6 30 68 6 Excessive Drinking 14 15 14 16 10 13 19 14 Alcohol impaired Driving Deaths 26 33 31 28 24 26 28 38 Sexually Transmitted Infections 543 6 456 3 362 1 302 1 853 5 955 0 615 2 545 1 Teen Births 36 44 44 47 43 39 24 38 Clinical Care 36 56 42 29 38 4 45 12 12 13 12 12 12 10 13 1 530 1 990 1 1 880 1 1 700 1 5 020 1 1 380 1 2 980 1 Uninsured Primary Care Physicians Dentists 2 140 1 3 310 1 4 640 1 4 530 1 8 420 1 7 480 1 2 040 1 10 160 1 Mental Health Providers 1 180 1 8 270 1 6 960 1 11 320 1 8 420 1 14 950 1 860 1 6 770 1 62 86 77 93 75 72 66 85 Diabetes Monitoring Preventable Hospital Stays 85 80 83 82 87 82 85 88 Mammography Screening 63 56 53 61 59 67 71 59 Social Economic Factors 30 21 42 65 54 16 49 High School Graduation 89 93 88 85 88 86 85 90 Some College 60 52 53 50 42 47 64 54 Unemployment 6 0 7 0 5 7 6 6 10 1 7 8 5 8 6 9 25 29 27 28 49 35 22 37 5 3 5 1 4 6 4 2 5 3 6 0 5 0 6 3 Children in Single parent Households 38 30 30 31 69 56 39 50 Social Associations 12 3 11 3 8 6 10 6 11 8 6 0 11 6 12 9 436 179 162 147 886 194 415 221 Children in Poverty Income Inequality Violent Crime Injury Deaths 77 95 71 96 86 67 60 92 Physical Environment 12 53 29 21 62 36 18 Air Pollution Particulate Matter 10 1 10 0 9 7 10 5 9 6 9 9 10 7 9 9 Drinking Water Violations No Yes No No No No No Severe Housing Problems 15 11 13 12 15 20 17 17 Driving Alone to Work 86 84 84 85 84 90 85 82 Long Commute Driving Alone 33 36 37 49 51 45 24 46 Compare across states with caution Note Blank values reflect unreliable or missing data 62

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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 30 million Americans have diabetes and face its devastating consequences What s true nationwide is also true in Alabama ALABAMA S DIABETES EPIDEMIC Approximately 634 000 people in Alabama or 15 4 of the adult population have diabetes Of these an estimated 127 000 have diabetes but don t know it greatly increasing their health risk In addition 1 334 000 people in Alabama 37 of the adult population have prediabetes with blood glucose levels higher than but not yet high enough to be diagnosed as diabetes 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 Every year an estimated 31 000 people 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 IMPROVING LIVES PREVENTING DIABETES AND FINDING A CURE In 2018 the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health invested 26 840 952 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 2015 state diagnosed diabetes prevalence cdc gov diabetes data 2012 state undiagnosed diabetes prevalence Dall et al The Economic Burden of Elevated Blood Glucose Levels in 2012 Diabetes Care December 2014 vol 37 Diabetes Incidence 2015 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 2018 NIDDK funding Projectreporter nih gov 2018 CDC diabetes funding www cdc gov fundingprofiles 63

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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 64 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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