Howard County General Hospital Community Health Needs Assessment And .

Howard County General Hospital ages 15-19 versus 29 Maryland and 20 national), premature death (3,842 years of potential life lost before 75 per 100,000 versus 6,459 Maryland and 5,200 national), and uninsured population (7% versus 12% Maryland and 11% national). Conversely, the County exceeds the average rate in other counties nationwide in indicators such as low birthweight babies (8% versus 5.9%), excessive drinking (15% versus 10%), and alcohol-impaired driving deaths (38% vs. 14%). See Table 6 below for additional details. Table 6. County Health Rankings 2015 – Howard County Howard Error County Margin Health Outcomes Length of Life Premature death 3,842 3,576-4,108 Quality of Life Poor or fair health Poor physical health days Poor mental health days Low birthweight babies Health Factors Health Behaviors Adult smoking Adult obesity Food environment index Physical inactivity Access to exercise opportunities Excessive drinking Alcohol-impaired driving deaths Sexually transmitted infections Teen births Clinical Care Uninsured Primary care physicians Dentists Mental health providers Preventable hospital stays Diabetic monitoring Mammography screening Top U.S. Performers Maryland 5,200 6,459 9% 2.4 2.5 8% 8-10% 2.1-2.7 2.2-2.8 7.7-8.4% 10% 2.5 2.3 5.9% 13% 3 3.2 9% 8% 23% 9.3 18% 98% 7-10% 21-26% n/a 16-20% n/a 14% 25% 8.4 20% 92% 15% 28% 8.2 23% 94% 15% 38% 14-18% n/a 10% 14% 15% 34% 164 11 n/a 10 to 12 138 20 451 29 7% 511:1 1,248:1 412:1 41 88% 66.3% 6-8% n/a n/a n/a 38-43 84-91% 62.9-69.6% 11% 1,045:1 1,377:1 386:1 41 90% 70.7% 12% 1,131:1 1,392:1 501:1 54 84% 64.6% 6

Howard County General Hospital Social & Economic Factors High school graduation Some college Unemployment Children in poverty Income inequality Children in single-parent households Social associations Violent crime Injury deaths Physical Environment Air pollution - particulate matter Drinking water violations Severe housing problems Driving alone to work Long commute - driving alone III. Howard County Error Margin Top U.S. Performers Maryland 90% 84% 4.9% 7% 3.6 22% n/a 81.7-86.3% n/a 5-8% 3.5-3.7 20-23% 93% 71% 4.0% 13% 3.7 20% 83% 67.5% 6.6% 14% 4.5 34% 8.7 201 33 n/a n/a 30-36 22 59 50 9 506 54 12.7 n/a 9.5 12.5 0% 13% 81% 46% n/a 12-14% 80-82% 44-47% 0% 9% 71% 15% 16% 17% 73% 47% Approach and Methodology The CHNA process for Howard County General Hospital included the collection and analysis of primary and secondary data. Members of public and private organizations, such as faith-based organizations, government agencies, educational systems and health and human services entities provided their assessment of the needs of the community. The 2014 CHNA served as a baseline to provide a deeper understanding of the health and socioeconomic needs of the community. Primary Data The 2014 Howard County Health Assessment Survey (HCHAS) was used for this CHNA. It is a biennial study first administered in 2012. Reaching more than 2,000 participants via a telephone survey it provided a wealth of direct information that would not have been attainable through individual hospital resources. The survey was jointly commissioned by the Horizon Foundation, the Howard County Health Department, Howard County General Hospital, and the Columbia Association. OpinionWorks, LLC provided the technical aspects of the survey, including recommendations on the precise wording of questions, population sampling, and telephone data collection. The fact sheets and website were developed by Simplicity Metrics. The organizations sponsoring the HCHAS jointly determined the questions that were asked. The survey approach, methodology, and questions were modeled after the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). This means that residents across the country have been asked many of the same questions and results from national studies may be effectively 7

Howard County General Hospital compared with Howard County results. Additional questions were added to the 2014 survey to gain more detailed information in certain areas. The survey assessed health-related behaviors and risk factors among the adult population of Howard County, Maryland. Results of this study have enabled local government, health providers and stakeholders to measure progress and determine where to focus resources for improved health outcomes particularly focused on reduction of health disparities. More than 2,000 residents participated in the phone survey between July 8 and August 18, 2014. In order to be compared geographically, the county was divided into five sampling areas, based on the seven regional planning areas, with the three westernmost planning areas combined into a single sampling area. Howard County households were dialed at random, and the first adult to answer the phone was asked to participate in the survey. Caregivers were not allowed to answer for others; answers for all study respondents reflected their own characteristics and experience. The survey was administered in English and in Spanish. As is common with telephone surveys, some populations were underrepresented (including African Americans and residents ages 18 to 34), while other groups were overrepresented (including whites, women, and residents over age 65). To ensure the survey results reflected the characteristics of the county, a statistical procedure known as weighting was used. The demographic profile of the survey was adjusted to be similar to the actual population, based on the most recent U.S. Census data. In short, the answers from those groups underrepresented in the sample count more when totaling up responses and calculating averages to accurately represent all residents. Secondary Data Information collected from secondary data provided essential information, insight and knowledge on a broad range of health and social issues. Data collected encompassed socioeconomic information, health statistics, demographics, children’s health, mental health issues, etc. The data sources included demographic information from Truven Health Analytics and the U.S. Census and reports and websites of local, state, and federal agencies, such as the U.S. Census American Community Survey, County Health Rankings, Maryland State Health Improvement Process (SHIP), and Howard Health Counts. Resource Inventory Howard County has many resources that contribute to its being identified as one of the healthiest counties in Maryland, according to the 2015 County Health Rankings. The location of the county is a perfect suburban location between Baltimore, MD and Washington, D.C. The high income level (more than 50% of households earn more than 100,000/yr), high rate of advanced education of residents (close to 60% have a college education or advanced degree) and a high rate of insured residents (97%) add greatly to the overall health of the community. 8

Howard County General Hospital A resource inventory was created to identify services available within the HCGH community area to assess any gaps in care. The inventory identifies organizations and agencies in the community that are serving the various target populations within each of the priority needs. The resource inventory appears in Appendix A. Local Health Improvement Coalition (LHIC) The Local Health Improvement Coalition (LHIC), a part of the State Health Improvement Plan (SHIP), was formed in 2012 and is responsible for guiding local health planning, specifically as it relates to addressing health disparities and inequities in the local community. After almost four years of combined efforts, focused interventions have occurred, groups are working more cohesively and expectations of improved outcomes are anticipated over time. In order to ensure broad based input of the community served by the Hospital, the LHIC, led by the HCGH President, Steven Snelgrove and the Howard County Health Officer, Maura Rossman, M.D., served as the task force for identifying and prioritizing the highest needs of the community in Howard County. The task force included leaders of local health and human service organizations, county government leadership, local business leaders and hospital leaders who provided input through their participation in this process. Health Experts The health experts for the August 2014 health survey were members of the Howard County Survey Planning Committee. LHIC membership also provided input during monthly meetings. Examples of the collaborative efforts between health experts appear in the Table 7 below. Table 7. Howard County Survey Planning Committee Organization Key Collaborator and Title LHIC Maura Rossman, M.D., Health Officer and LHIC co-chair Steve Snelgrove, HCGH President and LHIC co-chair Jeananne Sciabarra, LHIC Director Howard County Maura Rossman, M.D. , Health Health Department Officer Felicia Pailen, Dir., Policy and Planning Jacqueline Douge, M.D., Director Child Health Kati Moore, Health Policy Analyst Columbia Association Shawni Paraska, Dir., Community Health Sustainability Collaboration Description More than 40 member organizations voted to determine the health priorities for calendar years 2015-2017 in November 2014. Staff provided input on questions of interest for the survey that were reflective of community health needs. Assistance was given in the outreach to the community about the survey as well as a point of contact for the data analysis. Provided input on questions concerning healthy behaviors and physical activity. 9

Howard County General Hospital Horizon Foundation Glenn Schneider, Chief Program Officer Au’Sha Washington, Research Associate Tiffany Callender, Sr. Program Officer Provided coordination of the survey process, input into pertinent questions for the survey and agency contact for the consultant group performing the survey. Johns Hopkins Medicine Steve Arenberg, Dir. Marketing Research, JHM Elizabeth Edsall Kromm, Sr. Dir., Population Health and Community Relations Cindi Miller, Dir. Community Health Education, HCGH Provided advice on marketing research. Steve Rabe, President Provided expertise in survey question development, data collection and data summary. Howard County General Hospital OpinionWorks, LLC Provided input on HCGH Community Health Needs. Prioritization The LHIC served as the focus group and task force for the final determination of key priorities. Howard County General Hospital, a member of this group, contributed to the prioritization. All priorities were also to consider the following criteria: The level of disparities related to the health outcome. How improvement would affect large populations. How improvement can improve several health outcomes. The opportunity to control high cost and long-term impact while addressing the issue. How results could be quantified. For the 2015 HCGH CHNA, the LHIC Membership provided recommendations and support for the ongoing health priorities. They are local stakeholders with an active interest in health improvement and they are qualified to review current health status information and establish shared health improvement priorities. They represent diverse and important populations in Howard County. 10

Howard County General Hospital IV. Key Community Priorities The top priority needs were identified as: 1. Access to Affordable Care 2. Behavioral Health 3. Healthy Aging 4. Healthy Weight, (Exercise and Nutrition) These areas were consistent with the four areas voted as health priorities by HCGH in their first CHNA in 2012. They are also the four identified LHIC priorities for 2015-2017. Chronic disease is considered to be incorporated into the four prioritized needs, as it is believed that by addressing these targeted areas there will be improvements in chronic diseases and conditions. All four priority areas are interconnected with the prevalence of chronic disease and a major factor impacting healthy aging. An example of how chronic disease is addressed within healthy aging is through interventions such as referrals to the Community Care Team (CCT) at the time of hospital discharge. The CCT will address greater compliance of the discharge plan, thus allowing for greater control of chronic disease. The HCHAS results confirmed that Howard County is, on average, healthier than the rest of the country, but significant health challenges persist—especially among those with lower levels of income and education, as well as health outcomes related to everyday choices about smoking, drinking, diet, and exercise. Also, disparities still existed in access to care, with more than 10% of African Americans not having health insurance. Healthy weight improvement was very slight, and there were small changes in Emergency Department visits for behavioral health conditions. Please see Appendix B for the 2014 HCHAS report of findings, including a copy of the survey instrument. Access to Care The survey revealed that 15,229 residents currently do not have health insurance coverage. This number has decreased by about 2,700 since 2012. However, problems of inequality compared by income, race and education still remain. While 95% of residents have some type of health care coverage, only 88% of respondents in households making less than 50,000 a year have coverage, and only 88% of those with a high school diploma or GED have coverage. Respondents who identified their race as African American, Hispanic, or Native American/Other were more likely to experience health access difficulties. While 96% of White residents said they have health coverage, only 90% of African Americans, 90% of Hispanics, and 90% of those in the Native American/Other category report having coverage. Employment status also affected access to health care. For example, while 96% of those employed say they have some type of health insurance, only 90% of those who were self-employed and 78% of those unemployed were insured. Behavioral Health Women were more likely than men to report taking medication or receiving treatment from a doctor or other health professional for a mental or emotional condition (9% vs. 5%). Between 11

Howard County General Hospital 2012 and 2014, about the same percentage of residents reported being stressed about money for vital expenses, such as rent, mortgage, and food. However, respondents who identified their race as African American, Hispanic, or Native American/Other were more likely to experience this type of stress. 53% of White residents said they were never stressed about money for vital expenses, compared with 42% of African Americans, 28% of Hispanics, and 38% of those in the Native American/Other category. Additionally, there was a noticeable increase in residents aged 18 to 34 who reported binge drinking or having more than five drinks for men and four drinks for women, at least once in a month. In 2012, 20% of residents in this age group reported binge drinking at least once in a month, and in 2014 that percentage increased to 27%. Healthy Aging The population of older adults is growing, and this group is at high risk for developing chronic disease. Between 2012 and 2014 the same percentage of residents aged 50 – 64 reported having high blood pressure (35%), diabetes (10%) and COPD or another breathing condition (4%). This same age group reported a decrease in cholesterol (47% to 44%). Residents aged 65 and older had increases in high blood pressure (59% to 61%), cholesterol (50% to 56%) and diabetes (20% to 24%). Seniors 65 reported a decrease in COPD or other breathing condition (9% to 6%). Continued efforts to decrease aspects of chronic disease by encouraging lifestyle changes of medication compliance, healthy eating and physical activity will support reduction in these above measurements. Healthy Weight (Exercise and Nutrition) 56% percent of Howard County respondents reported BMI scores in the overweight or obese range, compared with 64% of Marylanders. Although fewer Howard County residents were overweight or obese compared to the State, many survey participants reported behaviors that contribute to unhealthy weight, including lack of exercise and low consumption of fruits and vegetables. When broken down by race, there were decreases in overweight/obesity rates among all races/ethnicities from 2012 to 2014, except a slight increase among White residents (55% to 59%) and a strong increase among Hispanic residents (39% to 53%). Additionally, residents earning less than 50,000 are getting more than 1 serving of fruit per day in 2014 (64%) compared to 2012 (46%). Other Needs HCGH is a comprehensive, acute-care medical center with 266 licensed beds specializing in women s and children’s services, surgery, cardiology, oncology, orthopedics, psychiatry, emergency services, outpatient therapy and services and community health education. To support the diverse health needs of the community, the hospital’s professional staff is comprised of more than 900 physicians and allied health professionals, representing nearly 100 specialties and subspecialties. Although the four identified needs in this 2016 CHNA do not encompass all health needs of the community, HCGH has a full community health and wellness program addressing many needs 12

Howard County General Hospital including those not specifically discussed here. More information can be found in the FY2015 Community Benefit Report (CBR) which can found online at: http://www.hopkinsmedicine.org/the johns hopkins hospital/about/in the community/com munity benefits.html. The hospital’s Wellness Center conducts over 500 classes, screenings and educational events addressing a full spectrum of community health needs. A few examples of programs and initiatives that are active at HCGH that address needs outside of the assessment key priorities are inclu

Source: Truven Health Analytics, 2015 and American Community Survey, 2015. Howard County General Hospital 5 Table 3. Race/Ethnicity Howard County Columbia CDP Maryland USA White-Non-Hispanic 168,266 (54.8%) 50.1% 53.6% 61.8% Asian & Pacific Is. Non-Hispanic Source: .