Towner County Community Health Needs Assessment: Towner County Medical Center, Cando, N.D.

_____________________________________________________________________________________________

_____________________________________________________________________________________________ Community Health Needs Assessment 2

Table of Contents

Introduction .....................................................................................................................................3

Towner County Medical Center ...................................................................................................4

Community, Health Care Facilities, and Other Resources .......................................................6

Assessment Methodology ..............................................................................................................7

Demographic Information .............................................................................................................11

Health Conditions, Behaviors, and Outcomes ............................................................................13

Survey Results .................................................................................................................................23

Findings of Key Informant Interviews .........................................................................................58

Priority of Health Needs ................................................................................................................61

Summary ..........................................................................................................................................62

Appendix A – Survey Instruments ...............................................................................................64

Appendix B – Community Group Members and Key Informants Participating in

Interviews .........................................................................................................................................84

Appendix C – County Health Rankings Model .........................................................................85

Appendix D – Definitions of Health Variables ...........................................................................86

Appendix E – Towner County Public Health District Community Profile ............................87

Appendix F – Lake Region District Health Unit Community Profile .....................................97

Appendix G – County Analysis by North Dakota Health Care Review, Inc. ........................124

Appendix H – Prioritization of Community’s Health Needs ...................................................132

_____________________________________________________________________________________________


Introduction

To help inform future decisions and strategic planning, Towner County Medical Center

(TCMC) in Cando, N.D., conducted a community health needs assessment. Through a

joint effort, Towner County Medical Center and the Center for Rural Health at the

University of North Dakota School of Medicine and Health Sciences analyzed

community health-related data and solicited input from community members and

health care professionals. The Center for Rural Health’s involvement was funded

through its Medicare Rural Hospital Flexibility (Flex) Program. The Flex Program is

federally funded by the Office of Rural Health Policy and as such associated costs of the

assessment were covered by a federal grant.

To gather feedback from the community, residents of the health care service area and

local health care professionals were given the chance to participate in a survey.

Additional information was collected through a Community Group comprised of

community members as well as through key informant interviews with community

leaders.

The purpose of conducting a community health needs assessment is to describe the

health of local people, identify use of local health care services, identify and prioritize

community needs, and help health care leaders begin to identify action needed to

address the future delivery of health care in the defined area. A health needs assessment

benefits the community by: 1) collecting timely input from the local community,

providers, and staff; 2) providing an analysis of secondary data related to health

conditions, risks, and outcomes; 3) compiling and organizing information to guide

decision making, education, and marketing efforts, and to facilitate the development of a

strategic plan; 4) engaging community members about the future of health care delivery;

and 5) allowing the community hospital to meet federal regulatory requirements of the

Affordable Care Act, which requires not-for-profit hospitals to complete a community

health needs assessment at least every three years.

_____________________________________________________________________________________________


Towner County Medical Center

Towner County Medical Center is 20-bed, critical access hospital located in Cando,

North Dakota. As a hospital and accredited level V trauma center, TCMC provides

comprehensive care for a wide range of medical and emergency situations. TCMC offers

many services, including inpatient and outpatient hospital care, long-term care, clinical

services, a partial hospital/medically monitored outpatient treatment facility, retirement

housing, and child care. With approximately 170 employees, TCMC is one of the largest

employers in the region, and has an estimated economic impact on the community of

approximately $6.85 million.1

The original Towner County Memorial Hospital was a 26-bed hospital built in 1952 with

funds raised by the people of Towner County and the Order of the Sisters of St. Francis.

The hospital nearly doubled in size in 1968 with an addition that included new patient

rooms, an ambulance garage, an emergency room, a new laboratory, and a radiology

room. In 1992, the ownership and direction of the hospital changed based on a

community initiative, and physical changes to the facility were made in 1995 to ensure

handicapped accessibility. Also added were a new medical clinic, dental clinic,

emergency room, a drive-through emergency garage, x-ray suite, physical therapy room,

nursing station, laboratory, medical records area, and birthing room.

Towner County Medical Center defines its mission as follows:

Towner County Medical Center (TCMC) provides: total quality comprehensive

healthcare; caring and compassionate health services for patients, residents,

families and healthcare workers; medical care for all life stages delivered by a

professional and expert healthcare team; and a commitment to our communities

to maintain and ensure the ongoing provision of quality health services.

1 Economic impact data were estimated using economic multipliers derived from MIG 2007

IMPLAN data.

_____________________________________________________________________________________________


Services offered locally by Towner County Medical Center include:

General and Acute Services

Cardiology (visiting

physician)

Clinic

Emergency room

Gynecology (visiting

physician)

Hospital (acute care)

Independent senior housing

Nutrition counseling

Obstetrics (visiting physician)

Ophthalmology evaluation

and surgery services (mobile)

Orthopedics (visiting

physician)

Pharmacy

Podiatry – evaluation and

surgery

Surgical services

Swing bed services

Screening/Therapy Services

Chiropractic services

Chronic disease

management

Holter monitoring

Laboratory services

Lower extremity

circulatory assessment

Massage therapy

Occupational physicals

Occupational therapy

Pediatric services

Physical therapy

Respiratory care

Sleep studies

Social services

Radiology Services

CT scan (mobile unit)

Digital mammography

(mobile unit)

General x-ray

Nuclear medicine (mobile unit)

MRI (mobile unit)

Ultrasound (mobile unit)

In addition to the rural health clinic and the hospital in Cando, TCMC also operates a

medical clinic in Devils Lake. TCMC also includes senior independent living housing,

basic care residential service, and skilled nursing residential service in Cando.

_____________________________________________________________________________________________


Community, Health Care Facilities, and Other Resources

Cando, located in northeastern North Dakota, is the county seat of the largest durum

wheat-producing county in the world. Access to major cities is within a reasonable

driving distance of Cando. Winnipeg, Manitoba, is less than three hours away, while

access to major shopping and medical facilities in North Dakota is within 40 miles. The

Cando public school system prepares students for vocational and post-secondary

training. Adult education courses also are offered.

Numerous recreational activities are available for residents of Cando with its city parks,

participatory and observational sports, athletic fields, a swimming pool and a nine-hole

golf course. Its city parks include facilities for tennis, baseball, volleyball, basketball, and

horseshoes. The Cando All Seasons Arena offers skating and hockey. Some of the state’s

best fishing may be found within 40 miles, and the area is abundant with waterfowl,

geese, and deer.

Health care facilities and services in the area (Benson, Ramsey, and Towner counties)

include the following:

Basic care facilities

Cando – 10-bed basic care facility

Devils Lake – 43-bed, 13-bed, and seven-bed basic care facilities

Edmore – 20-bed basic care facility

Maddock – 25-bed basic care facility

Nursing homes

Cando – 40-bed nursing home

Devils Lake – 52-bed and 74-bed nursing homes

Rural health clinics

Cando

Maddock

Pharmacies

Cando – one retail pharmacy in addition to the TCMC pharmacy

_____________________________________________________________________________________________


Devils Lake – three retail pharmacies in addition to the hospital and clinic pharmacies

Maddock

Assessment Methodology

Towner County Medical Center serves an area in northeastern North Dakota. Because a

large portion of the medical center’s patients come from the counties of Benson, Ramsey,

and Towner, this assessment focuses on data from those counties. In addition to Cando,

located in those counties are the North Dakota communities of Bisbee, Devils Lake,

Edmore, Esmond, Leeds, Maddock, Minnewaukan, Rocklake, and Starkweather.

Figure 1: Counties Included in Towner County Medical Center’s Service Area:

Benson, Ramsey, and Towner

The Center for Rural Health provided substantial support to Towner County Medical

Center in conducting this needs assessment. Center for Rural Health representatives

collected data for the assessment in a variety of ways: (1) a survey solicited feedback

from area residents; (2) another version of the survey gathered input from health care

professionals who work at Towner County Medical Center; (3) community leaders

representing the broad interests of the community took part in one-on-one key

informant interviews; (4) a Community Group comprised of community members and

_____________________________________________________________________________________________


health care professionals was convened to prioritize area health needs; and (5) a wide

range of secondary sources of data was examined, providing information on a multitude

of measures including demographics; health conditions, indicators, and outcomes; rates

of preventive measures; rates of disease; and at-risk activities.

The Center for Rural Health is one of the nation’s most experienced organizations

committed to providing leadership in rural health. Its mission is to connect resources

and knowledge to strengthen the health of people in rural communities. The Center

serves as a resource to health care providers, health organizations, citizens, researchers,

educators, and policymakers across the state of North Dakota and the nation. Activities

are targeted toward identifying and researching rural health issues, analyzing health

policy, strengthening local capabilities, developing community-based alternatives, and

promoting rural concerns.

As the federally designated State Office of Rural Health (SORH) for the state and the

home to the North Dakota Medicare Rural Hospital Flexibility (Flex) program, the

Center connects the School of Medicine and Health Sciences and the University of North

Dakota to rural communities and their health institutions to facilitate developing and

maintaining rural health delivery systems. In this capacity the Center works both at a

national level and at state and community levels.

Detailed below are the methods undertaken to gather data for this assessment by

convening a Community Group, conducting key informant interviews, soliciting

feedback about health needs via a survey, and researching secondary data.

Community Group

A Community Group consisting of 17 community members was convened and met on

June 17, 2013. During this Community Group meeting, group members learned about

the needs assessment process and reviewed basic demographic information about

Towner County. The group was then presented with survey results, findings from key

informant interviews, and a wide range of secondary data relating to the general health

of the population in the Towner County Medical Center service area. The group was

then tasked with identifying and prioritizing the community’s health needs. Members of

the Community Group are listed in Appendix B.

Interviews

One-on-one interviews with key informants were conducted by telephone on April 29,

2013 and May 1, 2013. A representative of the Center for Rural Health conducted the

_____________________________________________________________________________________________


interviews. Interviews were held with seven key informants who could provide insights

into the community’s health needs. Included among the informants was a public health

nurse with special knowledge in public health acquired through several years of direct

care experience in the community, including working with medically underserved, low

income, and minority populations, as well as with populations with chronic diseases.

Key informants represented the broad interests of the community, and included

representatives from agriculture, the business community, the faith community, law

enforcement, and social services. Those taking part in interviews are listed in Appendix

B.

Topics covered during the interviews included the general health needs of the

community, delivery of health care by local providers, awareness of health services

offered locally, barriers to using local services, perceptions about collaboration within

the community, local health care delivery concerns, broader community concerns,

reasons community members use local health care providers, and reasons community

members use other facilities for health care.

Survey

A survey was disseminated to gather feedback from the community. The survey was not

intended to be a scientific or statistically valid sampling of the population. Rather, it was

designed to be an additional tool for collecting qualitative data from the community at

large – specifically, information related to community-perceived health needs.

Two versions of a survey tool were distributed to two different audiences: (1)

community members and (2) health care professionals. Copies of both survey

instruments are included in Appendix A.

Community Member Survey

The community member survey was available to all residents of the Cando area. The

survey tool was designed to:

Understand community awareness about services provided by the local health

system and whether consumers are using local services;

Understand the community’s need for services and concerns about the delivery

of health care in the community;

Learn about broad areas of community and health concerns;

Learn of residents’ perceptions about community assets;

_____________________________________________________________________________________________


Determine preferences for using local health care versus traveling to other

facilities; and

Solicit suggestions and help identify any gaps in services.

Specifically, the survey covered the following topics: community assets, community

concerns, awareness and utilization of local health services, barriers to using local

services, perceptions about collaboration within the community, local health care

delivery concerns, reasons consumers use Towner County Medical Center and reasons

they seek care elsewhere, travel time to the nearest clinic and to TCMC, awareness and

support of TCMC’s foundation, support for exploring the possibility of TCMC merging

with a larger health system, demographics (gender, age, marital status, employment

status, income, and insurance status), and respondents’ current health conditions or

diseases.

The survey was available for completion online by all residents in the TCMC service

area. The survey was publicized by the hospital and in the local newspaper. Those

taking the survey remained anonymous, as the survey did not collect any identifying

information. The survey period ran for more than a month, beginning on April 29, 2013.

Fifty-five community member surveys were completed online.

Health Care Professional Survey

Employees of Towner County Medical Center were encouraged to complete a version of

the survey geared to health care professionals. Like the community member version, this

health care professional version of the survey was administered online only, and 30

surveys were completed. The version of the survey for health care professionals covered

the same topics as the consumer survey, although it sought less demographic

information and did not ask whether health care professionals were aware of the

services offered locally. Including both versions of the survey, 85 residents in the area

took part in the survey process.

Secondary Research

Secondary data were collected and analyzed to provide a snapshot of the area’s overall

health conditions, behaviors, and outcomes. Information was collected from a variety of

sources including the U.S. Census Bureau; the North Dakota Department of Health; the

Robert Wood Johnson Foundation’s County Health Rankings (which pulls data from 16

primary data sources); North Dakota Health Care Review, Inc. (NDHCRI); the National

Survey of Children’s Health Data Resource Center; the Centers for Disease Control and

_____________________________________________________________________________________________


Prevention; the North Dakota Behavioral Risk Factor Surveillance System; and the

National Center for Health Statistics.

Demographic Information

Table 1 summarizes general demographic and geographic data about Benson, Ramsey,

and Towner counties, which comprise the majority of Towner County Medical Center’s

service area.

TABLE 1: NORTH DAKOTA COUNTY INFORMATION AND DEMOGRAPHICS (From 2010 Census; 2011 and 2012 estimates used where available)

Benson County

Ramsey County

Towner County

North Dakota

Population, 2012 estimate 6,760 11,536 2,316 699,628

Population change, 2010-2012 1.5% 0.7% 3.2% 4.0%

Land area, square miles 1,389 1,186 1,025 69,001

People per square mile 4.8 9.6 2.2 9.7

White persons 44.3% 88.0% 96.2% 90.4%

Persons under 18 years 33.4% 21.6% 20.0% 22.1%

Persons 65 years or older 12.6% 18.0% 24.0% 14.4%

Median age 32.1 42.5 48.2 37.1

Non-English speaking 2.5% 4.0% 2.1% 5.3%

High school graduates 80.7% 85.4% 89.2% 90.0%

Bachelor’s degree or higher 10.6% 21.4% 20.5% 26.5%

Live below poverty line 36.3% 11.4% 9.8% 12.3%

Children under 18 in poverty 37% 18% 16% 15%

The data show that the populations of Benson, Ramsey, and Towner counties are not

growing at as fast of a rate as North Dakota’s, although Towner County’s growth

approaches that of the state average. Towner County is very rural, with only 2.2 people

per square mile, which makes it a frontier county. Also a frontier county, Benson County

averages 4.8 people per square mile. Ramsey County, which includes the city of Devils

Lake, has a population density (9.6 people per square mile) close to the state average (9.7

people per square mile). The fact that portions of the TCMC service area are rural has

implications for the delivery of services and residents’ access to care. Transportation can

be an issue for rural residents as can isolation, which can have many effects on health

status.

_____________________________________________________________________________________________


The data indicate that both Ramsey and Towner counties have a higher percentage of

individuals aged 65 or older than the North Dakota average, with nearly one in four

residents in Towner County, and nearly one in five residents in Ramsey County, aged 65

and older. Additionally, Ramsey and Towner counties both report a median age that is

higher than the state median, with Towner County’s median age more than 10 years

older than the state median. This may indicate a need for greater health care services to

attend to the aging population. Benson County, on the other hand, has a lower

percentage of people aged 65 or older than the state average, as well as a median age

that is five years younger than the state median.

In terms of poverty, Ramsey and Towner counties have poverty rates that are lower than

the North Dakota average rate, with Towner County’s rate being 2.5% lower than the

state average. Benson County had a substantially higher poverty rate than the state

average – nearly three times the state average. Children under 18 were more likely to be

in poverty in all three counties as compared to the rest of North Dakota, with Benson

County having a rate of children in poverty that was two and one-half times the state

average (37% vs. 15%).

The area tended to have a less educated workforce than the rest of North Dakota. The

educational backgrounds of area residents can affect a health care facility’s ability to find

qualified staff members. Towner County, home to the TCMC hospital, had a rate of

residents with a bachelor’s degree or higher that was six percentage points lower than

the state average (20.5% vs. 26.5%), while Ramsey County’s rate was five percentage

points lower and Benson County’s rate was 15 percentage points lower.

_____________________________________________________________________________________________


Health Conditions, Behaviors, and Outcomes As noted above, several sources were reviewed to inform this assessment. This data is

presented below in four categories: (1) County Health Rankings, (2) public health

community profiles, (3) preventive care data, and (4) children’s health. One other source

of information, the Gallup-Healthways Well-Being Index, shows that North Dakota

ranked 19th nationally in well-being during 2012. The index is an average of six sub-

indexes, which individually examine life evaluation, emotional health, work

environment, physical health, healthy behaviors, and access to basic necessities.

County Health Rankings

The Robert Wood Johnson Foundation, in collaboration with the University of

Wisconsin Population Health Institute, has developed the County Health Rankings to

illustrate community health needs and provide guidance for actions toward improved

health. In this report, counties are compared to national benchmark data and state rates

in various topics ranging from individual health behaviors to the quality of health care.

The data used in the 2013 County Health Rankings are pulled from 16 primary data

sources and then are compiled to create county rankings. Counties in each of the 50

states are ranked according to summaries of a variety of health measures. Those having

high ranks, such as 1 or 2, are considered to be the “healthiest.” Counties are ranked on

both health outcomes and health factors. Below is a breakdown of the variables that

influence a county’s rank. A model of the 2013 County Health Rankings – a flow chart of

how a county’s rank is determined – may be found in Appendix C. For further

information, visit the County Health Rankings website at

http://www.countyhealthrankings.org.

http://www.countyhealthrankings.org/

_____________________________________________________________________________________________


Health Outcomes

Mortality (length of life)

Morbidity (quality of life)

Health Factors

Health Behavior o Tobacco use o Diet and exercise o Alcohol use o Unsafe sex

Clinical Care o Access to care o Quality of care

Health Factors (continued)

Social and Economic Factors o Education o Employment o Income o Family and social support o Community safety

Physical Environment o Air quality o Built environment

Table 2 summarizes the pertinent information taken from County Health Rankings as it

relates to Towner County Medical Center’s service area in Benson, Ramsey, and Towner

counties. It is important to note that these statistics describe the population of each

county, regardless of where county residents choose to receive their medical care. In

other words, all of the following statistics are based on the health behaviors and

conditions of the county’s residents, not necessarily patients of Towner County Medical

Center.

For some of the measures included in the rankings, the County Health Rankings authors

have calculated a national benchmark for 2013. As the authors explain, “The national

benchmark is the point at which only 10% of counties in the nation do better, i.e., the

90th percentile or 10th percentile, depending on whether the measure is framed

positively (e.g., high school graduation) or negatively (e.g., adult smoking).”

Each of the county’s ranking also is listed in the tables below. For example, Towner

County ranks 12th out of 46 ranked counties in North Dakota on health outcomes and

17th on health factors. The variables followed by a red checkmark () indicate that on

that measure the county is not measuring up to the state average; the variables having a

blue checkmark () indicate that the county is not meeting the national benchmark on

that measure. Measures that are not highlighted in a color indicate that the county is

doing better than both the national benchmark and the state average. Appendix D sets

forth definitions for each of the measures.

_____________________________________________________________________________________________


TABLE 2: SELECTED MEASURES FROM COUNTY HEALTH RANKINGS – NORTH DAKOTA COUNTIES

Benson County

Ramsey County

Towner County

National

Benchmark

North Dakota

Ranking: Outcomes 45th 41st 12th (of 46)

Premature death 20,202 8,425 - 5,317 6,244

Poor or fair health 20% 12% 10% 10% 12% Poor physical health days (in past 30 days)

3.1 2.9 1.8 2.6 2.7

Poor mental health days (in past 30 days)

3.0 2.8 1.6 2.3 2.4

% Diabetic 11% 8% 10% - 8%

Ranking: Factors 45th 37th 17th (of 46) Health Behaviors

Adult smoking 34% 26% 13% 13% 19% Adult obesity 33% 32% 30% 25% 30%

Physical inactivity 34% 26% 27% 21% 26%

Excessive drinking 22% 29% 14% 7% 22%

Motor vehicle crash death rate

64 15 - 10 17

Sexually transmitted infections

1,457 376 223 92 357

Teen birth rate 93 45 - 21 28 Clinical Care

Uninsured 18% 12% 17% 11% 11%

Primary care physician ratio - 765:1 - 1,067:1 1,297:1

Mental health provider ratio - 2,294:1 - - 2,546:1 Preventable hospital stays 95 63 47 47 59 Diabetic screening 89% 89% 78% 90% 86%

Mammography screening 71% 76% 81% 73% 71% Physical Environment

Limited access to healthy foods

22% 6% 31% 1% 9%

Access to recreational facilities

15 17 0 16 12

Fast food restaurants - 48% 25% 27% 44%

Health Outcomes

With respect to health outcomes, Towner County generally was fairing favorably when

compared to the rest of North Dakota (except in terms of diabetes), while Benson and

Ramsey counties generally were fairing poorer than state averages. Both Benson and

Towner counties reported higher rates of diabetes than the state average, while Ramsey

_____________________________________________________________________________________________


County’s rate matched the state average. Benson County had a rate of premature death

that was more than three times the state average, and one in five adults in the county

reported being in poor or only fair health.

In terms of self-reported days per month of poor physical or mental health, Benson and

Ramsey counties showed elevated rates. Residents in these counties reported on average

more days each of month of poor physical and poor mental health than the state

averages. Towner County, on the other hand, showed rates of self-reported poor

physical or mental health days that beat the national benchmarks, placing it in the top

10% of counties nationally on these measures.

Health Factors In examining health factors, which include health behaviors, clinical care measures, and

the physical environment, several patterns emerge in the region served by TCMC. All

three counties were performing worse than the state averages in terms of rates of

physical inactivity of the counties’ residents and the number of uninsured residents.

Benson and Ramsey counties tended overall to perform more poorly on measures of

health behaviors than Towner County. Below is a more detailed examination of the

health factor measures for each of the counties.

Towner County

With respect to health factors, Towner County was not measuring up to the state

averages in several categories. Towner County showed results that were worse than the

state average (as well as the national benchmark) on the following measures:

Physical inactivity

Level of uninsured residents

Diabetic screening


Access to recreational facilities

Of these measures, the gap between the county rate and the state average was the most

pronounced in terms of uninsured residents, limited access to healthy foods, and access

to recreational facilities. The number of uninsured residents in Towner County was

approximately 50% higher than the state average. In examining the physical

environment of those living in Towner County, County Health Rankings makes clear

_____________________________________________________________________________________________


that options for healthy food and wellness and fitness activities are limited. As explained

below, this latter concern was echoed in the survey results, with health care

professionals ranking as the number one broad community concern the lack of sufficient

facilities for exercise and well-being.

Additionally, Towner County was not meeting the national benchmarks on the

following measures:

Adult obesity

Excessive drinking


The rate of excessive drinking (a measure that includes both binge drinking and heavy

drinking) in Towner County was twice the national benchmark, while the level of

sexually transmitted infections was more than twice the national benchmark. On the

positive side, the county was meeting the national benchmark – meaning it was

performing in the top 10% of counties nationally – in terms of adult smoking,

preventable hospital stays, mammography screening, and the prevalence of fast food

restaurants.

Benson County

Of the three counties, Benson County was performing worse than the state averages on

the most measures of health factors, often by a substantial amount. The county was

performing worse than the state average on:

Adult smoking

Adult obesity

Physical inactivity

Motor vehicle crash death rate


Teen birth rate

Uninsured residents

Preventable hospital stays


The most alarming gaps between the county rate and the state averages were in the

category of health behaviors. Benson County had a smoking rate 15 percentage points

higher than the state rate, a physical inactivity rate eight points higher than the state

average, a motor vehicle crash death rate more than three times the state average, a level

_____________________________________________________________________________________________


of sexually transmitted infections four times the state rate, and a teen birth rate more

than three times the North Dakota average. On a positive note, the county was besting

the state averages on the measures of diabetic screening, mammography screening, and

access to recreational facilities.

Ramsey County

Of the three counties, Ramsey County had the worst rate of excessive drinking and fast

food restaurant prevalence. It had the best rate of physical inactivity, percentage of

uninsured residents, and access to recreational facilities. Factors on which the county

was doing worse than the state average were:

Adult smoking

Adult obesity

Excessive drinking


Teen birth rate

Uninsured residents

Preventable hospital stays

Prevalence of fast food restaurants

The county was meeting the state average but not measuring up to national benchmarks

in terms of physical inactivity, motor vehicle crash death rate, diabetic screening, and

limited access to healthy foods. The county was meeting or besting the national

benchmarks (meaning it was performing in the top ten percent of counties nationally) on

the measures of primary care physician ratio, mammography screening, and access to

recreational facilities.

Public Health Community Health Profile

Included as Appendix E is the North Dakota Department of Health’s community health

profile for the Towner County Public Health District. Appendix F is the community

health profile for the Lake Region District Health Unit, which includes Benson and

Ramsey counties, among others. Data about leadings causes of death are from 2004 to

2008.

In Towner County, the leading cause of death for children aged 1 to 14 is suicides.

Unintentional injuries is the leading cause of death for those aged 25 to 44, while cancer

is the leading cause of death for those aged 45 to 74. Among the elderly, the leading

_____________________________________________________________________________________________


causes of death are heart-related and cancer for those in the 75 to 84 age bracket, and

heart-related for those aged 85 years and older. Other common causes of death include

cirrhosis, stroke, chronic obstructive pulmonary disease, diabetes, and hypertension. A

graph illustrating leading causes of death in various age groups in the public health unit

may be found in Appendix E.

In Benson County the leading causes of death for infants and children are anomalies for

those aged 0 to 4 and suicide for those aged 5 to 14. Unintentional injury is the most

common cause of death for those in the 15 to 34 age bracket, while cirrhosis the leading

cause of death of those aged 35 to 44. Heart disease tops the list of causes of death for

those aged 45 to 54 and those aged 85 and older. Cancer is the leading cause of death for

those aged 55 to 84. Other common causes of death include sudden infant death

syndrome, diabetes, stroke, chronic obstructive pulmonary disease,

pneumonia/influenza, and newborn respiratory distress. A graph illustrating leading

causes of death in various age groups in the county may be found in Appendix F.

In Ramsey County the leading cause of death for infants and children aged 0 to 4 is

prematurity. Suicide is the number one cause of death for those in the 15 to 34 age

bracket, while cancer claims the most lives in the 45 to 84 age group. Heart-related

deaths are most common for those aged 35 to 44 and those 85 years and older. Other

common causes of death include sudden infant death syndrome, unintentional injury,

cirrhosis, chronic obstructive pulmonary disease, and stroke. A graph illustrating

leading causes of death in various age groups in the county may be found in Appendix

F.

In assessing the region’s health needs, attention also should be paid to other information

provided in the public health profiles about quality of life issues and conditions such as

arthritis, asthma, cardiovascular disease, cholesterol, crime, drinking habits, fruit and

vegetable consumption, health insurance, health screening, high blood pressure, mental

health, obesity, physical activity, smoking, stroke, tooth loss, and vaccination.

Preventive Care Data

North Dakota Health Care Review, Inc., the state’s quality improvement organization,

reports rates related to preventive care. They are summarized Table 3 for Benson,

_____________________________________________________________________________________________


Ramsey, and Towner counties.2 For a comparison with other counties in the state, see the

respective maps for each variable found in Appendix G.

Those rates highlighted below in red signify that county is doing worse than the state

average on that measure.

TABLE 3: SELECTED PREVENTIVE MEASURES

Benson County

Ramsey County

Towner County

North Dakota

Colorectal cancer screening rates 45.1% 54.1% 53.2% 55.5%

Pneumococcal pneumonia vaccination rates

31.7% 52.7% 43.6% 51.3%

Influenza vaccination rates 41.4% 59.1% 57.7% 50.4%

Annual hemoglobin A1C screening rates for patients with diabetes

94.3% 95.7% 93.4% 92.2%

Annual lipid testing screening rates for patients with diabetes

86.3% 90.4% 75.4% 81.0%

Annual eye examination screening rates for patients with diabetes

62.1% 68.9% 77.0% 72.5%

PIM (potentially inappropriate medication) rates

10.0% 9.3% 11.9% 11.1%

DDI (drug-drug interaction) rates 7.6% 9.0% 12.2% 9.8%

The data indicate that the region comprising Towner County Medical Center’s service

area is generally fairing adequately as compared to the rest of North Dakota in terms of

certain indicators of preventive care. As the table above indicates, the area is doing

better than the state average on slightly more than half of the measures studied. All

three of the counties lagged the state average on colorectal cancer screening rates, and

two of the three counties were not measuring up to the state averages on pneumococcal

pneumonia vaccination rates and annual eye examination screening rates for diabetics.

Especially concerning was that Benson County was in the bottom quintile (bottom 20%)

of counties in the state on three of the measures: colorectal cancer screening rate,

2 The rates were measured using Medicare claims data from 2009 to 2010 for colorectal screenings, and

using all claims through 2010 for pneumococcal pneumonia vaccinations, A1C screenings, lipid test screenings, and eye exams. The influenza vaccination rates are based on Medicare claims data between March 2009 and March 2010 while the potentially inappropriate medication rates and the percent of drug-drug interactions are determined through analysis of Medicare part D data between January and June of 2010.

_____________________________________________________________________________________________


pneumococcal pneumonia vaccination rate, and annual eye examination screening rate

for diabetics.

Children’s Health The National Survey of Children’s Health touches on multiple intersecting aspects of

children’s lives. Data are not available at the county level; listed below is information

about children’s health in North Dakota. The full survey includes physical and mental

health status, access to quality health care, and information on the child’s family,

neighborhood, and social context. Data are from 2011-12. More information about the

survey may be found at: www.childhealthdata.org/learn/NSCH.

Key measures of the statewide data are summarized below. The rates highlighted in red

signify that the state is faring worse on that measure than the national average.

TABLE 4: SELECTED MEASURES REGARDING CHILDREN’S HEALTH (For children aged 0-17 unless noted otherwise)

Measure North Dakota National

Children currently insured 93.5% 94.5%

Children whose current insurance is not adequate to

meet child’s needs 23.8% 23.5%

Children who had preventive medical visit in past year 78.6% 84.4%

Children who had preventive dental visit in past year 74.6% 77.2%

Children aged 10-17 whose weight status is at or above

the 85th percentile for Body Mass Index 35.8% 31.3%

Children aged 6-17 who engage in daily physical activity 30.4% 28.0%

Children who live in households where someone smokes 29.8% 24.1%

Children aged 6-17 who missed 11 or more days of

school in the past year due to illness/injury 4.6% 6.2%

Young children (10 mos.-5 yrs.) receiving standardized

screening for developmental or behavioral problems 20.7% 30.8%

Children aged 2-17 who received needed mental health

treatment or counseling in last year 86.3% 61.0%

The data on children’s health and conditions reveals that while North Dakota is doing

better than the national averages on a few measures, it is not measuring up to the

national averages with respect to the percentages of children insured and children

_____________________________________________________________________________________________


whose insurance is adequate, preventive medical and dental visits, children at the 85th

percentile of Body Mass Index, children living in smokers’ households, and children

receiving standardized screening for developmental behavioral problems.

Importantly, more than 20% of the state’s children are not receiving an annual

preventive medical visit or a preventive dental visit. Lack of preventive care now affects

these children’s future health status. While the state is faring well compared to the rest

of the country in terms of children who received needed mental health care or

counseling, anecdotal evidence from the Center for Rural Health indicates that children

living in rural areas may be going without care due to the lack of mental health

providers in those areas.

Table 5 includes selected county-level measures regarding children’s health in North

Dakota. The data come from North Dakota KIDS COUNT, a national and state-by-state

effort to track the status of children, sponsored by the Annie E. Casey Foundation. KIDS

COUNT data focus on main components of children’s well-being; more information

about KIDS COUNT is available at www.ndkidscount.org. The measures highlighted in

red in the table are those on which the county is doing worse than the state average.

Data are from 2011.

As is apparent from the summary table, the TCMC service area is lagging behind state

averages on the examined measures relating to child well-being. Of the eight measures

examined for this assessment, all three counties were performing worse than the state

average on five of the measures, and two of the three counties were faring worse than

the state average on the remaining three measures. These measures show that there are

high percentages of children who are in poverty, are uninsured, and who rely on

governmental assistance. In Benson County, almost half of children aged 0-17 live in

poverty, compared to a state average of 14.2%. Almost three-quarters of the county’s

children are Medicaid recipients and more than 60% are beneficiaries of the

Supplemental Nutrition Assistance Program (SNAP). The rates of children in poverty in

Ramsey and Towner counties also exceed the state average, but not nearly to the degree

as in Benson County.

_____________________________________________________________________________________________


TABLE 5: COUNTY-LEVEL MEASURES REGARDING CHILDREN’S HEALTH

Benson County

Ramsey County

Towner County

North Dakota

Uninsured children (% of population age 0-18)

9.7% 6.8% 9.0% 5.8%

Uninsured children below 200% of poverty (% of population)

6.2% 3.8% 5.4% 3.4%

Medicaid recipient (% of population age 0-20)

72.9% 40.5% 34.0% 27.9%

Children enrolled in Healthy Steps (% of population age 0-18)

3.3% 3.0% 5.9% 2.4%

Children 0-17 living in poverty 48.3% 16.7% 17.1% 14.2%

Supplemental Nutrition Assistance Program (SNAP) recipients (% of population age 0-18)

63.5% 33.8% 22.7% 24.3%

Licensed child care capacity (% of population age 0-13)

6.4% 46.2% 30.4% 31.0%

High school dropouts (% of grade 9-12 enrollment)

8.4% 1.3% 2.2% 2.1%

Survey Results Survey Demographics

Two versions of the survey were administered: one for community members and one

for health care professionals. With respect to demographics, both versions asked

participants about their gender, age, and education level. In addition, health care

professionals were asked to state their professions and how long they have worked in

the community, and community members were asked about marital status, employment

status, household income, and travel time to the nearest clinic and to Towner County

Medical Center. Figures 2 through 14 illustrate these demographic characteristics of

health care professionals and community members.

Throughout this report, numbers (N) instead of percentages (%) are reported because

percentages can be misleading with smaller numbers. Survey respondents were not

required to answer all survey questions; they were free to skip any questions they

wished.

_____________________________________________________________________________________________


Community Members and Health Care Professionals

The demographic results from both the community member version and the health care

professional version of the survey revealed similar findings about several measures. In

both response groups, as illustrated in Figures 2 and 3, the number of females

responding was more than the number of males responding. In the case of community

members, female respondents outnumbered male respondents nearly three to one. That

difference was even more pronounced among health care professionals, with female

respondents outnumbering male respondents six to one.

Figure 2: Gender – Community Members

Figure 3: Gender – Health Care Professionals

A slight majority of community members who answered the question about their age

(N=26) were between the ages of 55 and 64. The next most represented group consisted

of those between the ages of 45 and 54 (N=10). The two smallest groups of community

36

14

Female

Male

24

4

Female

Male

_____________________________________________________________________________________________


members responding were the oldest and youngest sets, with no responses from those

75 years and older or those less than 25 years old. With respect to health care

professionals, the largest age group consisted of those aged 45 to 54 (N=10), followed by

those aged 25 to 34 (N=6). Figures 4 and 5 illustrate respondents’ ages.

Figure 4: Age – Community Members

Figure 5: Age – Health Care Professionals

Community members represented a wide range of educational backgrounds, with the

largest group (N=20) having a bachelor’s degree. The next largest groups consisted of

0

7

3

10

26

4

0

Less than 25 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 years and older

3

6

3 10

5

1

0

Less than 25 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 years and older

_____________________________________________________________________________________________


those with some college or a technical degree (N=13) and those with an associate’s

degree (N=8).

With respect to health care professionals, the largest group (N=11) consisted of those

with an associate’s degree. The next most represented group comprised those with some

college or a technical degree (N=6). Figures 6 and 7 illustrate the diverse educational

background of respondents.

Figure 6: Education Level – Community Members

Figure 7: Education Level – Health Care Professionals

0

3

13

8

20

6 Some high school

High school diploma orGED

Some college/technicaldegree

Associate's degree

Bachelor's degree

Graduate orprofessional degree

0

3

6

11

4

4 Some high school

High school diploma orGED

Some college/technicaldegree

Associate's degree

Bachelor's degree

Graduate orprofessional degree

_____________________________________________________________________________________________


Health Care Professionals

Health care professionals were asked to identify their specific professions within the

health care industry. As shown in Figure 8, respondents represented a range of job roles,

with the greatest response from nurses (N=9), clerical personnel (N=6), and “other”

(N=6). There was one response from a physician, but no responses from physician

assistants or nurse practitioners.

Figure 8: Jobs – Health Care Professionals

Health care professionals also were asked how long they have been employed or in

practice in the area. As shown in Figure 9, a majority of respondents (N=15) indicated

they have worked in the area for more than 20 years. There was a fairly even

distribution among the remaining groups, with the next largest group (N=6) indicating

working in the area for 10 to 20 years.

3

6

0 1 1

9

1 0

6

Allied health professional

Clerical

CNA/other assistant

Environmental services

Health care administration

Nurse

Physician

Physician Assistant/NursePractitionerOther

_____________________________________________________________________________________________


Figure 9: Length of Employment or Practice in Area – Health Care Professionals

Community Members

Community members were asked additional demographic information not asked of

health care professionals. This additional information included marital status,

employment status, household income, and their proximity to the nearest clinic and to

Towner County Medical Center.

A large majority of community members (N=46) identified themselves as married, as

exhibited in Figure 10.

Figure 10: Marital Status – Community Members

4

3

6

15

Less than 3 years

3 to 9 years

10 to 20 years

More than 20 years

0

46

2 1

Divorced/separated

Married

Single/never married

Widowed

_____________________________________________________________________________________________


As illustrated by Figure 11, a majority of community members (N=36) reported being

employed full time, followed by retired (N=5).

Figure 11: Employment Status – Community Members

Figure 12 illustrates the wide range of community members’ household income and

indicates how this assessment took into account input from parties who represent the

broad interests of the community served, including lower-income community members.

Of those who provided a household income, the most commonly reported annual

household income was $50,000-74,999 (N=11), followed by $35,000-49,999 (N=6) and

$75,000-99,999 (N=6). Two community members reported a household income of less

than $25,000, while 11 respondents indicated that they preferred not to answer this

question.

36

4

3

2

0 5

Full time

Part time

Homemaker

Multiple job holder

Unemployed

Retired

_____________________________________________________________________________________________


Figure 12: Annual Household Income – Community Members

Community members were asked how far they lived from Towner County Medical

Center in Cando and how far they lived from the nearest clinic. As shown in Figure 13, a

large majority of respondents answering this question (N=36) reported living within 10

minutes of Towner County Medical Center. A fifth of respondents (N=11) reported

living 10 to 30 minutes from TCMC. With respect to distance to the nearest clinic, as

shown in Figure 14, the results closely mirrored the results of the question about

distance from TCMC. Again, a large majority (N=34) respondents indicated living within

10 minutes from the nearest clinic, with another 10 respondents living 10 to 30 minutes

from the nearest clinic.

Figure 13: Respondent Travel Time to Towner County Medical Center

0

2 2

6

11

6 5

3

4

11

$0 to $14,999

$15,000 to $24,999

$25,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 to $199,999

$200,000 and over

Prefer not to answer

36

11

2 1

Less than 10 minutes

10 to 30 minutes

31 to 60 minutes

More than 1 hour

_____________________________________________________________________________________________


Figure 14: Respondent Travel Time to Nearest Clinic

Health Status and Access

Community members were asked to identify general health conditions and/or diseases

that they have. As illustrated in Figure 15, the results demonstrate that the assessment

took into account input from those with chronic diseases and conditions. The conditions

reported most often were high cholesterol (N=16), weight control (N=15), muscles or

bones (e.g., back problems, broken bones) (N=13), and hypertension (N=13).

Figure 15: Health Status - Community Members

34

10

5 1

Less than 10 minutes

10 to 30 minutes

31 to 60 minutes

More than 1 hour

0

0

1

2

4

5

6

8

11

13

13

15

16

0 2 4 6 8 10 12 14 16 18

Dementia

Heart conditions

Asthma/COPD

Chronic Pain

OB/GYN related

Cancer

Diabetes

Depression, stress, etc.

Arthritis

Hypertension

Muscles or bones

Weight control

High cholesterol

_____________________________________________________________________________________________


Community members also were asked what, if any, health insurance they have. Health

insurance status often is associated with whether people have access to health care. One

respondent reported having no health insurance or being under-insured. As

demonstrated in Figure 16, the most common insurance types were insurance through

one’s employer (N=35), private insurance (N=12), and Medicare (N=6).

Figure 16: Insurance Status – Community Members

General Community Concerns

Respondents were asked to review a list of 21 potential general community concerns

and rank each of them on a scale of 1 to 5 based on the importance of each potential

concern to the community, with 5 being more of a concern and 1 being less of a concern.

Community members collectively ranked maintaining enough health workers as the top

concern (4.14 on the 5-point scale). Other top concerns of community members were

insufficient facilities for exercise and well-being (3.94), aging population/lack of

resources to meet growing needs (3.86), and low wages/lack of livable wages (3.66).

Health care professionals included in their ranking three of the four same top

community concerns, although in a different order. Health care professionals included

lack of employees to fill positions in their top four concerns, but did not include aging

population/lack of resources to meet growing needs. Health care professionals also

tended to assign lower numerical rankings to the top concerns. Specifically, health care

professionals ranked the most important concerns as follows: insufficient facilities for

exercise and well-being (3.79), lack of employees to fill positions (3.61), maintaining

enough health workers (3.56), and low wages/lack of livable wages (3.50).

0

0

0

1

1

3

6

12

35

0 5 10 15 20 25 30 35 40

Indian Health Services

Tribal insurance

Veteran's Health Care Benefits

Medicaid

Uninsured/under-insured

Other

Medicare

Private insurance

Insurance through employer

_____________________________________________________________________________________________


The two groups of survey takers agreed on the two least important concerns, with

environmentally unsound/unfriendly place to live as the least important concern (1.80

for community members; 1.86 for health care professionals), and racism prejudice, hate,

discrimination (2.08 and 2.12) being the second least important concern.

Concerns that were perceived most differently between community members as

opposed to health care professionals were: impact of increased oil/energy production,

the ninth ranked concern among health care professionals and the 19th ranked concern

among community members; lack of employees to fill positions, second among health

care professionals and eighth among community members; and adequate availability of

child daycare, ninth among community members and 14th among health care

professionals.

Figures 17 and 18 illustrate these results.

_____________________________________________________________________________________________


Figure 17: General Community Concerns of Community Members

1.80

2.08

2.14

2.37

2.42

2.58

2.60

2.60

2.76

2.84

2.88

2.88

2.98

3.16

3.24

3.45

3.50

3.66

3.86

3.94

4.14

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Environmentally unsound/unfriendly place to live

Racism, prejudice, hate, discrimination

Impact of increased oil/energy development

Litter

Traffic safety

Adequate number of school resources

Crime and community violence

Lack of police presence in community

Domestic violence, including child abuse

Property taxes

Increasing population, including residents moving in

Poverty

Adequate availability of child daycare

Lack of employees to fill positions

Lack of affordable housing

Alcohol and drug use and abuse

Lack of employment opportunities

Low wages, lack of livable wages

Aging population/lack of resources

Insufficient facilities for exercise and well-being

Maintaining enough health workers

_____________________________________________________________________________________________


Figure 18: General Community Concerns of Health Care Professionals

In addition to assigning a 1-to-5 ranking to each potential concern, respondents also

were asked, in an open-ended question, how these concerns impact the community.

Fourteen community members answered this question, as did five health care

professionals.

Many community members and health care professionals pointed to a lack of

opportunity for young people other than low-paying jobs, and a perceived declining

population and loss of community vibrancy. One commenter, one the other hand, said

that “There is a definite population shift in Cando right now. Many new young families

1.86

2.12

2.25

2.26

2.31

2.35

2.41

2.42

2.44

2.44

2.50

2.54

2.82

3.18

3.26

3.44

3.46

3.50

3.56

3.61

3.79

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Environmentally unsound/unfriendly place to live

Racism, prejudice, hate, discrimination

Lack of police presence in community

Traffic safety

Adequate number of school resources

Litter

Crime and community violence

Adequate availability of child daycare

Poverty

Property taxes

Increasing population, including residents moving in

Domestic violence, including child abuse

Impact of increased oil/energy development

Alcohol and drug use and abuse

Lack of employment opportunities

Aging population/lack of resources

Lack of affordable housing

Low wages, lack of livable wages

Maintaining enough health workers

Lack of employees to fill positions

Insufficient facilities for exercise and well-being

_____________________________________________________________________________________________


are moving in and that is reflected in the enrollment numbers at the school. The

elementary students are outgrowing their building.”

Specific comments about these dynamics in the community included:

Lack of high quality, or educated employees to fill positions. Some of these low

paying jobs have brought some negative things to the area. (Drugs, making

people feel unsafe, kids who struggle or cause problems at school and are not

trusted in the community, strangers in town and kids hanging around

unsupervised, people living in sub-par housing.)

Low wages generally keep families in poverty and they cannot work their way

out.

Our community is less attractive to newcomers than it was 15 years ago. There

are really very few incentives to keep youth in the area when they finish their

educational years.

People move away or don't encourage others to move here.

Some potential job providers/industries, etc., have come into the community only

to pay a wage just at the poverty line. This does not contribute to community

growth and widens the gap between the haves and have-nots. It puts additional

pressure on social service and law enforcement personnel as well.

The low paying jobs attract many strangers to town. I think this contributes to

more drug flow in the community and that affects our safety. Also there seems to

be more people that come that do not work, but the system supports them (tax

payers support them). I am sure these people moving in and out must affect the

school and the need for more special education services.

The need for a STABLE increase in population will be vital for the community to

keep existing services available.

The poverty brings in several things that impact the community including: low

value housing options, crime, not knowing your neighbor, students at school

without parent support or students that are behind the other students in skills,

drugs, and many young people living off the system and not trying to work.

Basically it impacts the needs at the school and safety of the community.

We need to be able to keep the young generation here with paying jobs.

Community Health Concerns

Similar to the question about general community concerns, respondents were asked to

review a list of potential community health concerns and rank them on a scale of 1 to 5

based on the importance of each potential concern to the community, with 5 being more

_____________________________________________________________________________________________


of a concern and 1 being less of a concern. There was fairly strong alignment among

community members and health care professionals when ranking health concerns, with

both groups choosing the same top three concerns, although in a slightly different order.

Community members ranked as the top four health concerns the financial viability of

the hospital (4.32), higher costs of health care for consumers (4.20), adequate number of

providers/specialists (also 4.20), and not enough health care staff in general (3.90).

Health care professionals chose the same top three concerns and slotted in the fourth

spot access to needed technology/equipment. Specifically, the average rankings

provided by health care professionals were: financial viability of the hospital (4.14),

higher costs of health care for consumers (4.00), adequate number of

providers/specialists (3.68), and access to needed technology/equipment (3.61).

The two groups of survey-takers were in alignment with respect to the least important

concern. Both groups collectively ranked accident/injury prevention and the least

important concern (2.54 for community members and 2.37 for health care professionals).

Concerns that were perceived most differently between the two groups were: cancer,

which was the fifth highest ranked concern among community members and 10th among

health care professionals; and access to needed technology/equipment, fourth among

health care professionals and ninth among community members.

Figures 19 and 20 illustrate these results.

_____________________________________________________________________________________________


Figure 19: Community Health Concerns of Community Members

2.54

2.90

2.94

3.04

3.13

3.21

3.22

3.26

3.30

3.41

3.50

3.56

3.65

3.90

4.20

4.20

4.32

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Accident/injury prevention

Violence

Distance/transportation to health care facility

Emergency services available 24/7

Suicide prevention

Addiction/substance abuse

Focus on wellness and prevention of disease

Obesity

Access to needed technology/equipment

Diabetes

Mental health

Heart disease

Cancer

Not enough health care staff in general

Adequate number of providers/specialists

Higher costs of health care for consumers

Financial viability of hospital

_____________________________________________________________________________________________


Figure 20: Community Health Concerns of Health Care Professionals

As with the question about general community concerns, in addition to assigning a 1-to-

5 ranking to each potential health concern, respondents also were asked, in an open-

ended question, how these concerns impact the community. Seven community members

answered this question, as did four health care professionals.

Commenters pointed to a number of issues, including the aging population, attracting

and retaining physicians and other health care workers, mental health needs, and the

financial position of the local hospital. Some of these comments included:

Access to health care is very good right now, but I worry about retaining and

adding providers and the technologies to support them with limited financial

capacity of the health center.

Having access to a well-staffed and good hospital is key!

Lack of physicians is an overall concern.

Maintaining health care professionals so that there is continuity for clients. It is

frustrating to go to the clinic, of which you have been going to for 30 years and

feel that no one knows you or your history. It is like always starting all over

again.

2.37

2.43

2.61

2.79

2.82

2.89

3.26

3.32

3.32

3.32

3.39

3.39

3.46

3.61

3.68

4.00

4.14

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Accident/injury prevention

Emergency services available 24/7

Violence

Distance/transportation to health care facility

Suicide prevention

Addiction/substance abuse

Focus on wellness and prevention of disease

Cancer

Mental health

Obesity

Diabetes

Not enough health care staff in general

Heart disease

Access to needed technology/equipment

Adequate number of providers/specialists

Higher costs of health care for consumers

Financial viability of hospital

_____________________________________________________________________________________________


Mental health care services are few and when a family needs help it is too

difficult to get adequate and timely help.

Patients and families may have to travel over two hours for assessments and

treatments that may be inaccessible due to physician/ staff shortages locally.

People leave town to get health care and other things not available here. Then

while one is in Grand Forks they shop and eat and take away from several

businesses in town.

Preventive medicine is the best medicine. A fitness center would promote better

emotional, mental, and physical for all who use the resource.

We are an aging community. Many older people leave the community to be

closer to consistent specialized medical care.

Awareness of Services

The survey asked community members whether they were aware of the services offered

locally by Towner County Medical Center. The health care professional version of the

survey did not include this inquiry as it was assumed they were aware of local services

due to their direct work in the health care system. The survey question was asked in

subparts, with locally available services divided into three categories: (1) general and

acute, (2) screening and therapy, and (3) radiology.

Community members taking the survey generally were aware of many of the services

offered by Towner County Medical Center and other local providers. Community

members were most aware of the following services (with the parenthetical number

indicating the number of survey takers responding that they were aware of the service):

Independent senior housing (N=48)

Swing bed services (N=45)

Hospital (acute care) (N=43)

Chiropractic services (N=42)

Physical therapy (N=40)

Massage therapy (N=39)

MRI (mobile unit) (N=39)

Emergency room (N=38)

CT scan (mobile unit) (N=38)

Social services (N=37)

_____________________________________________________________________________________________


Respondents were least aware of the following services (again, with the parenthetical

number indicating the number of survey takers responding that they were aware of the

service):

Lower extremity circulatory assessment (N=19)

Holter monitoring (N=20)

Pharmacy (N=28)

Chronic disease management (N=28)

Nuclear medicine (mobile unit) (N=28)

Obstetrics (visiting physician) (N=29)

Ophthalmology evaluation and surgery services (mobile) (N=29)

Gynecology (visiting physician) (N=30)

Nutrition counseling (N=30)

Occupational physicals (N=31)

These services with lower levels of awareness may present opportunities for further

marketing, greater utilization, and increased revenue. Figures 21 to 23 detail community

members’ awareness of local services.

Figure 21: Community Members’ Awareness of Locally Available General and Acute

Health Care Services

28

29

29

30

30

33

34

35

35

36

38

43

45

48

0 10 20 30 40 50

Pharmacy


Ophthalmology evaluation/surgery (mobile)

Gynecology (visiting physician)


Cardiology (visiting physician)

Clinic

Orthopedics (visiting physician)

Podiatry – evaluation and surgery

Surgical services

Emergency room


Swing bed services


_____________________________________________________________________________________________


Figure 22: Community Members’ Awareness of Locally Available Screening/Therapy

Services

Figure 23: Community Members’ Awareness of Locally Available Radiology Services

Health Service Use

Community members were asked to review a list of services provided locally by Towner

County Medical Center and indicate whether they had used those services at TCMC, at

another facility, or both. Figures 24 to 26 illustrate these results.

Community members responding indicated that the services most commonly used

locally were:

19

20

28

31

32

32

33

34

36

37

39

40

42

0 10 20 30 40 50

Lower extremity circ. assessment

Holter monitoring

Chronic disease management


Pediatric services

Sleep studies

Laboratory services

Respiratory care


Social services

Massage therapy

Physical therapy


28

34

36

36

38

39

0 10 20 30 40 50



Digital mammography (mobile unit)

General x-ray


MRI (mobile unit)

_____________________________________________________________________________________________


Clinic (N=42)

Laboratory services (N=36)

General x-ray (N=35)

Chiropractic services (N=27)


Digital mammography (mobile unit) (N=23)

Ultrasound (mobile unit) (N=21)

Massage therapy (N=19)

Physical therapy (N=17)

CT scan (mobile unit) (N=12)

Pharmacy (N=11)

MRI (mobile unit) (N=11)

Respondents indicated that the services they most commonly sought out of the area

were:

Pharmacy (N=14)

Gynecology (N=12)

Clinic (N=11)

Hospital (acute care) (N=11)

Surgical services (N=9)

Ophthalmology evaluation and surgery services (N=9)

Laboratory services (N=8)

CT scan (N=8)

General x-ray (N=6)


Orthopedics (N=6)

As with low-awareness services, these services – for which community members are

going elsewhere – may provide opportunities for additional education about their

availability from the local health system and potential greater utilization of local

services.

_____________________________________________________________________________________________


Figure 24: Community Member Use of Locally Available General and Acute Health

Care Services

Figure 25: Community Member Use of Locally Available Screening/Therapy Services

0

0

0

2

2

5

5

6

6

6

9

11

25

42

1

9

1

2

5

5

6

12

5

9

11

14

6

11

0 20 40 60


Ophthalmology evaluation/surgery (mobile)

Swing bed services



Cardiology (visiting physician)

Orthopedics (visiting physician)

Gynecology (visiting physician)

Podiatry – evaluation and surgery

Surgical services


Pharmacy

Emergency room

Clinic

Used atTCMC

Used atAnotherFacility

0

1

1

1

2

5

5

6

9

17

19

27

36

1

1

2

1

3

1

2

1

2

2

3

5

8

0 20 40 60

Social services

Holter monitoring

Lower extremity circulatory assessment

Respiratory care

Chronic disease management

Pediatric services

Sleep studies



Physical therapy

Massage therapy


Laboratory services

Used atTCMC


_____________________________________________________________________________________________


Figure 26: Community Member Use of Locally Available Radiology Services

Additional Services

In another open-ended question, both community members and health care

professionals were asked to identify services they think Towner County Medical Center

needs to add. Seven community members provided a response to this question, as did

12 health care professionals. The most requested service, by a nearly two-to-one margin

over the next most often requested service, was the addition of a fitness and wellness

center. Five health care professionals suggested it, as did two community members.

Also requested – by three health care professionals and one community member – was a

full-time doctor who could provide continuity of care. Other services that were

requested by two or more survey respondents were: dialysis, enhanced radiology

equipment (including a CT scanner), and daycare services.

Reasons for Using Local Health Care Services and Non-Local Health Care Services

The survey asked community members why they seek health care services at Towner

County Medical Center and why they seek services at another health care facility. Health

care professionals were asked why they think patients use services at TCMC and why

they think patients use services at other facilities. Respondents were allowed to choose

multiple reasons.

Community members most often chose convenience (N=41) and loyalty to local service

providers (N=31) as the reasons for seeking care at TCMC. Other reasons commonly

cited by community members for seeking care at TCMC were proximity and familiarity

with providers (N=27 for both). Health care professionals also chose convenience (N=24)

as the top reason as to why patients seek care at TCMC, but collectively chose familiarity

with providers (N=22) as the next most common reason for consumers to seek care

2

11

12

21

23

35

2

4

8

5

4

6

0 20 40 60


MRI (mobile unit)



Digital mammography (mobile unit)

General x-ray

Used atTCMC


_____________________________________________________________________________________________


locally. Health care professionals chose loyalty to local service providers (N=17) as the

third top reason as to why they think patients seek care locally at TCMC. Figures 27 and

28 illustrate these responses.

Figure 27: Reasons Community Members Seek Services at Towner County Medical

Center

1

4

5

6

8

10

13

15

22

22

27

27

31

41

0 10 20 30 40 50

Disability access

Other

Transportation is readily available

Less costly

They take new patients

Access to specialist

Confidentiality

Open at convenient times

High quality of care

They take my insurance

Familiarity with providers

Proximity

Loyalty to local service providers

Convenience

_____________________________________________________________________________________________


Figure 28: Reasons Health Care Professionals Believe Community Members Seek

Services at Towner County Medical Center

With respect to the reasons community members seek health care services at other

facilities, community members and health care professionals were in agreement that the

primary motivator for seeking care elsewhere was, by a considerable margin, that

another facility has a needed specialist (N=38 for community members; N=24 for health

care professionals). Other oft-cited reasons for seeking care elsewhere were high quality

care (N=21 for community members and N=13 for health care professionals) and

confidentiality (N=19; N=8). These results are illustrated in Figures 29 and 30.

1

5

5

5

6

7

8

11

13

15

16

17

22

24

0 5 10 15 20 25

Other


Disability access

Less costly


Confidentiality

We take many types of insurance


Proximity

We take new patients




Convenience

_____________________________________________________________________________________________


Figure 29: Reasons Community Members Seek Services at Other Health Care Facilities

Figure 30: Reasons Health Care Professionals Believe Community Members Seek

Services at Other Health Care Facilities

0

0

2

3

4

5

5

6

6

6

9

19

21

38

0 10 20 30 40 50

Disability access


Proximity



Less costly

Other

Convenience



They take my insurance

Confidentiality



1

1

2

2

3

3

5

6

6

7

7

8

13

24

0 5 10 15 20 25


Other

Disability access

Loyalty to service providers

Less costly


Convenience


Proximity


They take many types of insurance

Confidentiality



_____________________________________________________________________________________________


Barriers to Accessing Health Care

Both community members and health care professionals were asked what would help to

address the reasons why patients do not seek health care services in the Cando area.

There was not as much alignment between the responses of the two groups of survey-

takers to this question as there was in other questions. Community members focused on

the inability to see the same provider over time (N=31) and the lack of doctors overall

(N=29). Health care professionals, meanwhile, ranked lack of affordability (N=17) as the

most pervasive barrier to using local care. Among both groups, lack of doctors was the

second most commonly cited reason while lack of specialists was the third most

commonly cited reason. Community member saw lack of evening or weekend hours as

the fourth largest barrier to care (N=9), while health care professionals ranked that

choice much lower (N=4), placing it the bottom half of potential barriers to care.

See Figures 31 and 32 for additional items that may help remove barriers to local health

care use.

Figure 31: Community Members’ Perceptions of Barriers to Using Local Care

0

0

2

3

4

5

5

5

7

8

9

13

29

31

0 10 20 30 40 50

Lack of transportation services

Language barriers

Other

Distance from health facility

Limited access to telethealth technology

Inability to get an appointment

Lack of affordability

Lack of confidentiality

Lack of insurance

Lack of awareness of local services

Lack of evening or weekend hours

Lack of specialists

Lack of doctors

Inability to see same provider over time

_____________________________________________________________________________________________


Figure 32: Health Care Professionals’ Perceptions of Barriers to Using Local Care

Concerns and Suggestions for Improvement

Each version of the survey concluded with an open-ended question that asked, “Overall,

please share concerns and suggestions to improve the delivery of local health care.”

Responses were supplied by 15 community members and seven health care

professionals. The most consistent theme to emerge from these comments was that the

community needs a full-time, long-term physician and other dedicated health care

workers. Commenters also mentioned financial issues, working conditions, the

possibility of merging with a larger health system, and the management of the hospital

Specific comments that reflected concerns about these and other issues included:

Concern that we could lose local control if we merged with another provider.

Would like to see more nurse practitioners or doctors who are in Towner

County.

Consistent providers; more public information on services provided and/or

available on-site and through visiting specialists. More annual emphasis on

0

1

1

2

3

4

4

5

9

11

12

12

15

17

0 5 10 15 20 25

Other

Inability to get an appointment

Language barriers

Limited access to telethealth technology

Lack of confidentiality

Lack of evening or weekend hours

Lack of transportation services

Distance from health facility

Lack of awareness of local services

Lack of insurance

Inability to see same provider over time

Lack of specialists

Lack of doctors

Lack of affordability

_____________________________________________________________________________________________


giving through foundation. Presence of providers, staff and others in the

community.

Doctors.

Getting providers who stay and are scheduled on a dependable basis. Keep

trying to bring in whatever services we can to continue bringing patients here.

Once a patient has been sent to a specialist, let them know we can follow-up that

care here-bring them back once we send them to someone else.

Having at least one full time doctor.

Having qualified doctors on staff in case of emergency.

I believe that there is an issue with higher administration. There is such a

turnover in staff there because of this, and because other businesses in Cando can

offer better pay, and better working environments.

I have confidentiality issues with some of the clinic nurses. I know (because I

have heard them myself) that they talk to outside people about others' health

conditions and share their opinions about people regarding their health issues.

I think if a new patient comes in and has no insurance they should pay at least

half the amount if not the full price.

I think merging with another facility would not be a bad idea, I have major

concerns that we may cost them too much and they shut down the facility.

I think that TCMC would be greatly improved with the access to 24/7 CT

scanning.

I think Towner County Medical Center does a good job of providing good,

accessible care.

If the viability of our clinic/hospital is in question, merging with a larger

provider to keep the doors open would be a very good thing. I don't think

people realize how much they appreciate having a clinic/hospital in the

community until it is gone. I hope this is something that never happens in this

community.

Keep trying to add new permanent providers. Provide some consistency for the

area.

Keeping a CEO for a longer period of time and keeping the same doctors in the

Cando clinic so you can go to the same physician each time would help a lot.

More genuine doctors and family nurse practitioners there to assist and help.

Need good doctors and dedicated hard working nurses.

Need more permanent doctors or physician assistants with regular working

hours, not just staff that works one day a week or month.

_____________________________________________________________________________________________


Signage to advertise DLCC and TCMC. Some people don't even know the clinic

is in the mall!

TCMC needs to get more doctors, to hire people who are effective and will stay

so that we have continuity, have no idea if is non-profit and/or if has/who is on

the board.

The cost of a DOT physical is approximately $150. I was informed by several

truck drivers that they can get one for $75 in a nearby city. Our high costs are a

big concern. We need another full time doctor.

Towner county living center needs more staff. I would like to see locals get paid

what "traveling nurses" get paid.

Awareness and Support of Foundation

Area residents were surveyed on their awareness and support of the hospital’s

foundation. Community members first were asked, “Are you aware of Towner County

Medical Center’s foundation (known as Rising to the Challenge), which exists to

financially support TCMC?” As shown in Figure 33, a majority of community members

(N=31) indicated that they were aware of the foundation, and an even greater share of

health care professionals (N=23) knew about the foundation.

Figure 33: Are You Aware of the TCMC Hospital Foundation?

Community Members Health Care Professionals

Respondents next were asked whether they had supported the TCMC foundation in any

of a number of enumerated ways. Respondents were allowed to choose more than one

response. Twenty-four community members answered this question, as did 15 health

care professionals. As illustrated in Figure 34, equal numbers of both community

31

18 Yes

No

23

5

Yes

No

_____________________________________________________________________________________________


members and health care professionals indicated they supported the foundation through

cash/stock gifts and memorials/honorariums.

Figure 34: Support of the TCMC Foundation

When choosing “other,” respondents were permitted, in an open-ended format, to list

other ways they have supported the foundation. These responses included volunteering,

participating in hospital auxiliary events, and through specific fundraisers.

Affiliation with Larger Health System Respondents were asked, “If Towner County Medical Center were offered the

opportunity to merge with a larger health system, do you agree that this is an idea

worth considering?” As shown in Figure 35, community member were more receptive to

this possibility, with approximately two-thirds either strongly agreeing or agreeing that

the idea merits consideration. Health care professionals, on the other hand, were less

enthusiastic, with less than half strongly agreeing or agreeing, and a plurality (N=10)

indicating they were neutral on this issue.

0

6

11

11

2

7

7

0 5 10 15 20

Planned gifts through wills,trusts or life insurance…

Endowment gifts

Other

Memorial/Honorarium

Cash or stock gift

CommunityMembers

Health CareProfessionals

_____________________________________________________________________________________________


6

6 10

2

1 3

Health Care Professionals

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Don't Know

Figure 35: Do You Agree that TCMC’s Merger with a Larger Health System is an Idea

Worth Considering?

Collaboration

Respondents were asked whether Towner County Medical Center could improve its

levels of collaboration with other local entities, such as schools, economic development

organizations, local businesses and industry, public health, other providers, and

hospitals in other cities. Of the three answer choices (“Yes,” “No, it’s fine as is,” “Don’t

know”), both community members and health care professionals were more likely to

choose “Yes” than “No, it’s fine as it is” – in some cases by fairly substantial margins –

with respect all categories of potential collaborators. Community members were most

likely to see a need for collaboration between TCMC and hospitals and clinics in other

cities, other local health providers, and local job and economic development

organizations. Health care professionals saw the most need for collaboration with local

job and economic development organizations, hospitals and clinics in other cities, and

public health. Figures 36 and 37 illustrate these results.

11

22

9

3

1 4

Community Members

StronglyAgreeAgree

Neutral

Disagree

StronglyDisagreeDon't Know

_____________________________________________________________________________________________


Figure 36: Community Members – Could Towner County Medical Center Improve

Collaboration?

Figure 37: Health Care Professionals – Could Towner County Medical Center Improve

Collaboration?

Community Assets

Both community members and health care professionals were asked what they

perceived as the best things about their community in five categories: people, services

and resources, quality of life, geographic setting, and activities. In each category,

respondents were given a list of choices and asked to pick the top three. Respondents

occasionally chose less than three or more than three choices within each category. The

results indicate that residents view as community assets (those items garnering more

than 50 responses) things such as friendly and helpful people, quality schools and youth

programs, health care, a family-friendly environment, safety and safe places to live, and

22

24

27

28

28

30

16

9

9

8

11

13

9

13

11

10

9

7

0 20 40 60

Public Health

Schools

Business and industry

Local job/economic development

Other local health providers

Hospitals and clinics in other cities

Yes

No, it's fine as is

Don't know

12

13

14

14

15

18

10

7

9

9

9

6

4

6

3

3

2

2

0 10 20 30

Schools

Business and industry

Other local health providers

Public Health

Hospitals and clinics in other cities

Local job/economic development

Yes

No, it's fine as is

Don't know

_____________________________________________________________________________________________


the relatively small size and scale of the community. Figures 38 to 42 illustrate the

results of these questions.

Figure 38: Best Things about the PEOPLE in Your Community

Figure 39: Best Things about the SERVICES AND RESOURCES in Your Community

2

6

7

11

14

19

28

42

6

4

0

5

8

9

20

24

0 20 40 60 80 100

Tolerance, inclusion, open-mindedness

Sense that you can make a difference -government is accessible

Other

Forward-thinking ideas (e.g. social values,government)

Community is socially and culturallydiverse and/or becoming more diverse

People aware of/engaged in social, civic,or political issues

Sense of community/feeling connectedto people who live here

People are friendly, helpful, supportive

CommunityMembers


4

6

7

8

10

15

34

38

2

3

1

4

6

8

24

18

0 20 40 60 80 100

Restaurants and food

Downtown and shopping

Other

Academic opportunities andinstitutions

Transportation

Public services and amenities

Health care

Quality school systems/educationalinstitutions/youth programs

CommunityMembers


_____________________________________________________________________________________________


Figure 40: Best Things about the QUALITY OF LIFE in Your Community

Figure 41: Best Things about the GEOGRAPHIC SETTING of Your Community

0

0

3

27

30

35

42

1

0

3

10

16

21

25

0 20 40 60 80 100

Other

Hustle and bustle of oil patch

Economic/employment opportunities

Informal, simple, laidback lifestyle

Healthy place to live

Safety and safe places to live, little/nocrime

Family-friendly environment; good placeto raise kids

CommunityMembers


0

2

9

11

11

22

24

29

37

0

4

2

5

1

13

17

18

22

0 20 40 60 80 100

Other

Waterfront, rivers, lakes, and/or beaches

Mix of rural and city areas

General beauty of environment and/orscenery

Climate and seasons

Natural setting: outdoors and nature

General proximity to work and activities(e.g., short commute, convenient access)

Cleanliness of area (e.g., fresh air, lack ofpollution and litter)

Relatively small size and scale ofcommunity

CommunityMembers


_____________________________________________________________________________________________


Figure 42: Best Thing about the ACTIVITIES in Your Community

Findings from Key Informant Interviews The questions posed in the survey also were explored during key informant interviews

with community leaders and public health professionals. As an initial matter,

interviewees generally were very complimentary toward hospital staff and their overall

presence in the community. As one key informant summarized, “The staff are very

reliable and well trained.” Another continued, “The staff do a really good job.”

Several themes emerged from these interviews. Many of the same issues that were

prevalent in the survey results emerged during the key informant interviews as well, but

additional issues also appeared. Generally, overarching issues that developed during the

interviews can be grouped into four recommendations (listed in no particular order):

1. Maintain a full-time physician

2. Aging population, lack of resources to meet growing needs

3. Hospital financial viability

4. Increase confidentiality

A more detailed discussion about these noteworthy issues follows:

6

8

8

31

32

33

3

10

3

13

18

18

0 20 40 60 80 100

Other

Specific events and festivals (e.g.,parades, fireworks, etc.)

Year-round access to fitnessopportunities

Activities for families and youth

Arts and cultural activities and/orcultural richness of community

Recreational and sports activities

CommunityMembers


_____________________________________________________________________________________________


1. Maintain a full-time physician

A majority of respondents expressed concern about the lack of continuity of care with

their primary care physician. The inconsistency of health care providers has negatively

impacted patients as they may be more likely to travel elsewhere to have the assurance

of a regular provider. As one participant expressed, “You see a different person every

time you have a need.”

Respondents expressed that the inability to keep a doctor on staff creates larger

problems. Residents can’t make a relationship with the doctor and the high turnover

rate results in a lack of trust. Additionally, people may avoid care because they don’t

know which provider they may get. It was reported that some residents “drag their feet”

or delay care because they don’t know the provider. The uncertainty of who a patient

may see on a particular day creates fear, which is especially problematic for elderly

patients. Older patients are also reported to not feel comfortable seeing a Physician

Assistant (PA). They want to see “a real doctor” and they are willing to travel outside of

Cando to do so. There also is a perception that mid-level health care providers like PAs

do not feel comfortable treating serious health conditions and will issue a referral.

Patients may skip seeing the local provider altogether if they know that traveling will be

the end result.

While residents are aware that recruiting a doctor in a small town is difficult, there was a

strong desire for the stability of a full time physician. Some interviewees were unsure if

TCMC even had a physician on staff or on an everyday basis. One commented, “there

are no doctors.” Some respondents said that TCMC did have a physician but explained

that he wanted to retire. To keep public informed of new services and changes, it was

recommended that TCMC advertise in the local newspaper.

Along the lines of maintaining a full time physician was the request to retain people in

interim positions. In addition to continuity in physicians, a desire also was expressed for

continuity with respect to those in leadership roles.

2. Aging population, lack of resources to meet growing needs

Respondents were well aware of the aging population in Towner County. An elderly

population has unique health care needs that interviewees tapped into such as

transportation services. Senior residents need specialized treatment for which they have

to travel outside of the community to receive, and obtaining transportation is

_____________________________________________________________________________________________


problematic for some. Another concern was that the nursing home doesn’t have the

ability to care for those with Alzheimer’s. Finally, respondents suggested that programs

that cater to the elderly like Meals on Wheels need to be expanded to the surrounding

communities.

3. Hospital financial viability

Appreciation for the hospital was repeatedly expressed. The hospital is perceived as a

huge community asset, valued both for its economic impact as well as its health services.

It is perceived as key to vitality in the community in terms of opportunities for

employment, growth and the future. Some specific comments attesting to this value are:

Great for the city—lots of jobs.

Strong community commitment.

Hometown touch care—superior care and service.

Makes you feel secure to have care here.

Rural hospitals are so important; we are so fortunate.

Hospital is key to vitality in community.

Because of the importance people place on the hospital there is grave concern about its

financial viability. There is a large concern that the hospital cannot make ends meet.

Along with that concern comes the fear that the hospital will close and a large number of

employment opportunities will be lost.

4. Increase confidentiality

There is a community perception that TCMC is not a good place to work nor a good

employer, which has caused a high turnover rate amongst health care providers. There

is some animosity towards the hospital pertaining to what is perceived as its sub-par

facility and inadequate service. Rumors have spread that the hospital has run off doctors

and even though the rumors may be false, one respondent commented “they might as

well be true as they hold a lot of stock in a small town.” Breaches in confidentiality

among staff were mentioned as well as the high visibility of seeking services in a small

town. As one respondent said, “everyone knows if you are there.” It was urged that the

staff needs to limit “gossiping” and increase confidentiality. There also is a perception

that TCMC charges more, billing at a higher level than other facilities for the same

services.

_____________________________________________________________________________________________


Additional Issues

An theme that emerged from the interviews was a consensus on adding local

dentistry services. When asked what specific services to you think TCMC needs

to add, dental services was the leading response.

The availability of child care also was deemed as inadequate. There is a need for

more evening child care, especially for single mothers who work nights.

A very specific request was made to fix the outside door. A new air seal is

needed as the door is too heavy to open.

Priority of Health Needs

The Community Group, consisting of 17 members, met on June 17, 2013. While the

community at large was invited to attend the meeting, most of the group members were

employees of TCMC. A representative from the Center for Rural Health presented the

group with a summary of this report’s findings, including background and explanation

about the secondary data, highlights from the results of the survey (including perceived

community health and community concerns, why patients seek care at TCMC,

community collaboration, and barriers to care), and findings from key informant

interviews.

Following the presentation of the assessment findings, and after careful consideration of

and discussion about the findings, all members of the group were asked to identify on a

ballot what they perceived as the top five community health needs. Group members

were advised they could consider a number of criteria when prioritizing needs, such as a

need’s burden, scope, severity, or urgency, as well as disparities associated with the

need and the overall importance the community places on addressing the need. The

results were totaled, and the concerns most often cited were:

Financial viability of the hospital (14 votes)

Access to needed technology and equipment (9 votes)

Elevated rate of diabetics (8 votes)

Elevated rate of uninsured residents (8 votes)

Lack of a stable, full-time physician (8 votes)

Based on the Community Group’s feedback about the prioritization of community

health needs, the needs were categorized into four groups: those receiving eight or

more votes (listed above), those receiving three to seven votes, those receiving one or

_____________________________________________________________________________________________


two votes, and those receiving no votes. A summary of this prioritization may be found

in Appendix H.

Summary

This study took into account input from approximately 110 community members and

health care professionals from the area served by Towner County Medical Center. This

input represented the broad interests of the community. Together with secondary data

gathered from a wide range of sources, the information gathered presents a snapshot of

health needs and concerns in the community.

An analysis of secondary data reveals that a large part of the Towner County Medical

Center service area – Towner and Ramsey counties – has a higher percentage of adults

over the age of 65 than the state average and higher median age than the state median,

with nearly one in four residents aged 65 or older in Towner County, and nearly one in

five residents aged 65 or older in Ramsey County. This likely indicates increased need

for medical services to attend to an aging population. The area is very rural: While

North Dakota has an average of 9.7 people per square mile, Towner County has on

average only 2.2 people per square mile and Benson County has on average 4.8 people

per square mile.

The data compiled by County Health Rankings show that with respect to health

outcomes, Towner County was generally faring favorably when compared to the rest of

North Dakota, except in terms of diabetes. Benson and Ramsey counties, on the other

hand, were generally faring poorly as compared to other North Dakota counties. An

examination of health factors, which include health behaviors, clinical care measures,

and physical environment, revealed several patterns in the region. All three counties

were performing worse than the state averages in terms of the rates of physical inactivity

of the counties’ residents and the number of uninsured residents. Benson and Ramsey

counties were performing worse than the state averages on a large number of the

measures, while Towner County was performing somewhat better.

In Towner County, where TCMC is based, the county was not measuring up to the state

averages with respect to physical activity, level of uninsured residents, diabetic

screening, limited access to healthy foods, and access to recreational facilities. Of these

measures, the gap between the county rate and the state average was most pronounced

in terms of uninsured residents, limited access to healthy foods, and access to

recreational facilities. The number of uninsured residents in Towner County was nearly

_____________________________________________________________________________________________


50% higher than the state average. On the positive side, the county was scoring in the

top 10% of counties nationally on the measures of adult smoking, preventable hospital

stays, mammography screening, and the prevalence of fast food restaurants.

Results from the survey revealed that among community members the top four

community health concerns were: (1) financial viability of the hospital, (2) higher costs

of health care for consumers, (3) having adequate numbers of health care providers and

specialists, and (4) not enough health care staff in general. Health care professionals

agreed with community members as far as ranking the top three community health

concerns. Health care professionals slotted in the fourth position access to needed

technology and equipment.

When asked about potential broader community needs, community members and health

care professionals were in alignment on three of the top four concerns, although not

necessarily in the same order. Community members ranked as their top four concerns:

(1) maintaining enough health care workers, (2) insufficient facilities for exercise and

well-being, (3) aging population/lack of resources to meet growing needs, and (4) low

wages/lack of livable wages. Health care professionals’ top community concerns were:

(1) insufficient facilities for exercise and well-being, (2) lack of employees to fill

positions, (3) maintaining enough health care workers, and (4) low wages/lack of livable

wages.

The survey also revealed generally good awareness of locally available health care

services and that residents choose to receive care locally due to convenience, loyalty to

local service providers, proximity, and familiarity with providers. Residents travel out of

the area for service primarily for access to necessary specialists and because of perceived

high quality care.

Input from Community Group members and community leaders provided via key

informant interviews echoed many of the concerns raised by survey respondents.

Thematic concerns emerging from these interviews were (1) maintaining a full-time

physician, (2) aging population and a lack of resources to meet growing needs, (3) the

financial viability of the hospital, and (4) a need for increased confidentiality.

Following careful consideration of the results and findings of this assessment,

Community Group members determined that the top health needs or issues in the

community are the financial viability of the hospital, access to needed technology and

equipment, elevated rate of diabetics, elevated rate of uninsured residents, and the lack

of a stable, full-time physician.

_____________________________________________________________________________________________


Appendix A1 – Community Member Survey Instrument

_____________________________________________________________________________________________


_____________________________________________________________________________________________


Appendix A2 – Health Care Professional Survey Instrument

_____________________________________________________________________________________________


_____________________________________________________________________________________________


Appendix B – Community Group Members and Key Informants

NAME TITLE ORGANIZATION

Kim Belzer Board member TCEDC

Cyndi Bennington Director Lakes Social Service District

Brad Bergdahl Board member TCEDC

Nancy Baerwald Vice President CountyBank USA

Lori Dunham Vice President First State Bank of Cando

Rosemary Goeser Medical records TCMC

Heidi Halverson RN TCMC

Michael Halverson Maintenance director TCMC

Tabitha Halvorson Lab supervisor TCMC

Ruth Ann Held Pharmacist TCMC

Pat Klingenberg Human resources TCMC

Nicki Kvislen Housekeeping supervisor TCMC

Carol Lang LPN TCMC

Tammy Larson Chief Financial Officer TCMC

Jeff Miller Farmer

Ivan Mitchell Chief Executive Officer TCMC

Lori Murchie Nutrition services director TCMC

Darrin Roberts Towner County Deputy

Sheriff

Towner County Sheriff’s Office

Charlene Ryan Chief Nursing Officer TCMC

Lynette Shock Clinic nursing manager TCMC

Robin Spencer Reception supervisor TCMC

Sherry Walters Executive Director Towner County Public Health

District

Bonnie Weaver Pastor Cando Lutheran Church

Nadine Weippert Business office manager TCMC

_____________________________________________________________________________________________


Appendix C – County Health Rankings Model

_____________________________________________________________________________________________


Appendix D – Definitions of Health Variables

Definitions of Health Variables from the County Health Rankings 2011 Report

Variable Definition

Poor or Fair Health

Self-reported health status based on survey responses to the question: “In

general, would you say that your health is excellent, very good, good, fair,

or poor?”

Poor Physical Health Days

(in past 30 days)

Estimate based on responses to the question: “Thinking about your physical

health, which includes physical illness and injury, for how many days

during the past 30 days was your physical health not good?”

Poor Mental Health Days

(in past 30 days)

Estimate based on responses to the question: “Thinking about your mental

health, which includes stress, depression, and problems with emotions, for

how many days during the past 30 days was your mental health not good?”

Adult Smoking Percent of adults that report smoking equal to, or greater than, 100

cigarettes and are currently a smoker

Adult Obesity Percent of adults that report a BMI greater than, or equal to, 30

Excessive Drinking

Percent of as individuals that report binge drinking in the past 30 days

(more than 4 drinks on one occasion for women, more than 5 for men) or

heavy drinking (defined as more than 1 (women) or 2 (men) drinks per day

on average

Sexually Transmitted

Infections Chlamydia rate per 100,000 population

Teen Birth Rate Birth rate per 1,000 female population, ages 15-19

Uninsured Adults Percent of population under age 65 without health insurance

Preventable Hospital Stays Hospitalization rate for ambulatory-care sensitive conditions per 1,000

Medicare enrollees

Mammography Screening Percent of female Medicare enrollees that receive mammography screening

Access to Healthy Foods Healthy food outlets include grocery stores and produce stands/farmers’

markets

Access to Recreational

Facilities Rate of recreational facilities per 100,000 population

Diabetics Percent of adults aged 20 and above with diagnosed diabetes

Physical Inactivity Percent of adults aged 20 and over that report no leisure time physical

activity

Primary Care Provider

Ratio Ratio of population to primary care providers

Mental Health Care

Provider Ratio Ratio of population to mental health care providers

Diabetic Screening Percent of diabetic Medicare enrollees that receive HbA1c screening.

Binge Drinking

Percent of adults that report binge drinking in the last 30 days. Binge

drinking is consuming more than 4 (women) or 5 (men) alcoholic drinks on

one occasion.

_____________________________________________________________________________________________


Appendix E – Towner County Community Health Profile

_____________________________________________________________________________________________


_____________________________________________________________________________________________


Appendix F – Lake Region Community Health Profile

_____________________________________________________________________________________________


_____________________________________________________________________________________________


Appendix G – County Analysis by North Dakota Health Care Review, Inc.

_____________________________________________________________________________________________


_____________________________________________________________________________________________


Appendix H – Prioritization of Community’s Health Needs

Tier 1

Financial viability of the hospital (14 votes)

Access to needed technology and equipment (9 votes)

Elevated rate of diabetics (8 votes)

Elevated rate of uninsured residents (8 votes)

Lack of a stable, full-time physician (8 votes)

Tier 2

Elevated rate of physical inactivity (7 votes)

Limited access to recreational facilities (5 votes)

Elevated rate of adult obesity (4 votes)

Lack of employees to fill positions (4 votes)

Higher costs of health care for consumers (3 votes)

Tier 3

Elevated level of sexually transmitted infections (2 votes)

Decreased rates of preventive screening (diabetic screening) (2 votes)

Limited access to healthy foods (2 votes)

Elevated level of uninsured children/children in poverty (2 votes)

Adequate number of health care providers and specialists (2 votes)

Not enough health care staff in general/maintaining enough health workers (2 votes)

Aging population/lack of resources to meet needs (2 votes)

Low wages, lack of livable wages (2 votes)

Need for improved collaboration (1 vote)

(No Votes)

Elevated rate of adult smoking – in surrounding counties

Elevated rate of excessive drinking

Elevated motor vehicle crash death rate – in surrounding counties

Elevated teen birth rate – in surrounding counties

Increase confidentiality

Towner County Community Health Needs Assessment: Towner County Medical Center, Cando, N.D.

Documents

Transcript of Towner County Community Health Needs Assessment: Towner County Medical Center, Cando, N.D.