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IntroductionThis Community Health Improvement Plan (CHIP) was developed through the leadership of the Madison County-London City Health District and 35 community representatives from 18 organizations who formed a Steering Committee, and was facilitated by Wright State University’s Center for Urban and Public Affairs. The development process was completed on August 21, 2014. These organizations partnered (1) to assess the community’s health using Mobilizing for Action through Planning and Partnerships (MAPP), and (2) to develop evidence-based solutions in response to the findings. MAPP was selected as the improvement model approach because this model provides a framework that ensures the inclusion of community planning essentials—a good structure for conducting the work, wide community collaboration, thorough use of qualitative and quantitative data, and guidance for evidence based research and prioritization.

The CHIP was developed based on the primary and secondary data analysis and efforts carried out in the development of the Community Needs (Health) Assessment. That research effort included: interviews with 55 community leaders; a demographic analysis; a survey of 400 adult residents selected at random; focus group sessions with chronic disease patients at the Free Clinic and with low income women convened by the Madison County Department of Job and Family Services; as well as analysis of data from Madison Health (hospital), the Ohio Department of Health, Ohio Department of Job and Family Services, Mental Health & Recovery Board, Robert Wood Johnson Foundation and Centers for Disease Control and Prevention, the National Survey on Drug Use and Health, and the Bureau of the Census’ American Community Survey. The study addresses secondary data for maternal and infant health data, behavioral risk factors, clinical and preventive services, diseases (such as cancer), hospital and emergency department discharge data, and leading causes of death.

Vision and ValuesThe steering committee came together on April 9, 2014 to develop vision and value statements that would guide the Madison County Community Health Improvement Plan. It was decided that important elements to include in the vision and values statements are healthy lifestyles, optimal health for all, and educating people about healthy choices. The following vision statement captures community leader guidance to the Community Health Improvement Plan.

Working together, we in Madison County commit to improve community health and wellness by empowering individuals to achieve the highest quality of life.

The following value statements guided the selection of the strategic priorities to be addressed in the CHIP: Madison County seeks to cultivate individual and community involvement in all aspects of our

health and wellness by empowering people and organizations toward achieving the highest quality of life

Madison County values building community to improve social circumstances and economic development

Madison County values every sector of the community as a partner in improving the quality of life

Madison County promotes positive community action

Madison County Community Health Improvement Plan December 2014 1

Community Health Improvement ProcessThe Community Health Improvement Process is a comprehensive approach to assessing community health and developing and implementing action plans to improve community health through community member and partner engagement. The community health improvement process includes two parts:

The community health assessment engages community members and partners to collect and analyze health-related data and information from a variety of sources. The findings of the community health assessment inform community decision-making, the prioritization of health problems, and the development and implementation of a community health improvement plan.

The community health improvement plan is action-oriented and outlines the community health priorities based on the community health assessment, community leader input, and communitywide input. The plan presents community health priorities and how they will be addressed to improve the health of the community.

This document presents the Madison County Community Health Improvement Plan which was developed by the Community Health Improvement Steering Committee (see page 3 for a list of members), and was facilitated by Wright State University’s Center for Urban and Public Affairs, with contract fees paid through a grant from the Ohio Public Health Partnership. The plan was largely informed by the community health assessment and guided by evidence based research. The steering committee followed the Mobilizing for Action through Planning and Partnership (MAPP) framework in 3 meetings:

Conducting forces of change, community themes and strengths, local public health system, and community health status assessments to create the Community Health Assessment

Developing strategic issues based on the community health assessment findings and based on the expertise of steering committee members

Identifying overarching goals, objectives and strategies to address the strategic issues Writing clear objectives and determining performance measures to monitor implementation

and improvement Creating action plans that determined the steps to implement chosen strategies, who would

lead and support the implementation, the short-term and longer term outcomes, and the time frame for implementation.


Community Health Improvement Steering Committee Members

Akers, Julie Madison Health

Ansel, Carol Madison County Board of Developmental Disabilities

Baldwin, Sherry Family Council

Baynes, Pat Madison County Senior Center

Ben, Tom London City Schools

Boerger, Mike Madison County Trustee Association

Burns, Deanna A Friend’s House

Burns, Erica A Friend’s House

Canney, Melissa Madison County Health Partners Free Clinic

Comer, Lexi Madison County/London City Health District

Dhume, David Madison County Commissioners

Dodge-Dorsey, Lori Madison County Department of Job and Family Services

Eldridge, Laura Action for Children

Florea, Nancy Miami Valley Child Development

Herman, Jane Bluebird Retirement Community

Houser, Linda Madison County Board of Health

Husek, Kathy Madison County/London City Health District

Hyden, Susie Madison County/London City Health District

Lane, Bridget Madison County/London City Health District

Lang, Danielle Community Action Organization

Lentz, Pat Madison County/London City Health District

Michaelson, Jennifer Madison County/London City Health District

Moore, Megan A Friend’s House

Peters, Chris Madison Health

Radcliff, Wanetta Community Action Organization


Roddy, Ruth Madison Health

Runnels, Roselin Mental Health Recovery Board

Stern, Carly Madison Health

Stout, Cindy Madison Health

Thomas, Lori Madison County Department of Family and Children

Tomlinson, Annie Mt. Sterling Community Center

Treadway, Jamie A Friend’s House

Vermillion, Cheryl Madison County/London City Health District

Webb, Mary Ann Madison County/London City Health District

Young, Susan Madison County/London City Health District

Priority Selection and Strategy Development ProcessThe steering committee carried out a three-step priority setting process to identify the health issues of greatest importance to the community. In the first step, researchers at Wright State University partnered with Madison Health (hospital), and used the criteria of prevalence, seriousness, and impacts on other health issues to begin the process of culling through the data. These two partners worked separately and then compared results. In the second step, the steering committee came together to review the results of all four MAPP assessments (forces of change, community themes and strengths, the local public health system, and the community health status) and underlined key health issues that cut across the assessments. After that effort, Madison Health and University identified priorities were shared, and this resulted in the first draft of strategic issues as follows.

Drug abuse prevention Adequate affordable housing Job placement and training & child care Food security Smoking cessation Promote healthy lifestyles Support to grandparents who are raising grandkids Diabetic education Access to Care: Primary care physicians recruitment Lung assessment Mental health promotion

In the third step, the steering committee applied the questions of the PEARL Test and narrowed the focus down to four strategic issues. The PEARL Test asks:


Propriety – Is a program for the health problem suitable? Economics – Does it make economic sense to address the problem? Are there economic

consequences if a problem is not addressed? Acceptability – Will a community accept the program? Is it wanted? Resources – Is funding available or potentially available for a program? Legality – Do current laws allow program activities to be implemented?

Drug abuse was the number one neighborhood problem identified by residents in general and by low income residents responding to a statistically representative survey conducted of adults in Madison County. Agencies and organizations involved in the planning process also identified the need for drug abuse prevention as a top priority for the County. Given that the community has already established a Drug Free Coalition, the CHIP Steering Committee decided that no duplicative effort was necessary; however, the Drug Free Coalition is invited to report its progress alongside the CHIP effort, which will report progress and outcomes three times a year to the Family Council. The four priority health topics identified for the CHIP are:

1. Healthy Lifestyles and Diabetes/Food Security2. Smoking Cessation and Lung Assessments3. Mental Health Promotion4. Access to Health Care

In the fourth step, the steering committee applied the following questions to ensure that truly strategic issues had been identified.

1. Is the issue related to the vision?2. Will the issue affect the entire community?3. Is the issue something that will affect the community now and into the future?4. Will the issue require changes in the way organizations/systems function?5. In order to address the issue, is leadership support needed or is there already a leadership group

in place addressing this issue sufficiently?6. Are there long term consequences of not addressing this issue?7. Does the issue require the involvement of more than one organization?8. Does the issue create tension in the community?

Based on this discussion, the four topics were organized as strategic issues and arranged in the form of a question, to serve as the foundation for the development of the CHIP. Four task force chair persons were identified and task force members were recruited. Two task forces were chaired by the Madison County-London City Health Department, one was chaired by Madison Health, and one was chaired by the Mental Health and Recovery Board. (See Appendix C)


The four strategic questions assigned to the task forces were:

1. Priority: Healthy Lifestyles, Diabetes Education and Food Security Strategic Issue: How do we improve control of diabetes through education and modify

community norms in regard to nutrition and physical activity? Background: Many people go outside of the County for health services; we need to promote

the services that we have locally. Recognizing the decrease in the federal Supplemental Nutrition Assistance Program (SNAP), the aim is to ensure that Food Pantries offer healthy food options, especially in the geography federally designated as a food desert where the social determinants of health indicate a need for strategic focus.

2. Priority: Lung Assessment and Smoking Cessation/Prevention Strategic Issue: How do we improve the overall lung health of the population? Background:

o Those who may be interested in a lung assessment include those affected by second-hand smoke, those who smoke tobacco products, those with asthma, and so on.

o Research indicates a relationship between dopamine and a smoking addiction. Dopamine is released in large quantities in the limbic system, the part of the brain responsible for motivation and reward. Nicotine enters the blood and after about seven seconds, it enters the brain, affecting exactly the same dopamine receptors, giving the brain the message that a rewarding activity has just been performed.

o In Madison County, 13.3% of adults had been told by their doctor that they had asthma and 6.7% had been told that they have COPD, emphysema or chronic bronchitis. Lung and bronchus cancer is the number two cancer in the County. Acute respiratory infections are the number two adult ED discharge diagnosis and COPD and allied conditions are number five. Similarly, pneumonia and influenza are the number one adult inpatient diagnosis in the County, and COPD and allied conditions is the number three inpatient diagnosis. Finally, Chronic Lower Respiratory disease is the number six leading cause of deaths in the adult population.

3. Mental Health Promotion Strategic Issue: How do we remove social barriers to treatment and increase access to

mental health services? Background:

o There is insufficient funding for mental health services in the Countyo Out-of-county pursuit of services hindered by the high-cost of transportation

serviceso Community barriers: denial, some people won’t seek services, there is a mental

health stigma, and there is resistance to receiving a mental health diagnosiso Mental health is a broad term, addressing: peer support, life challenges, and

behavioral health


4. Access to Health Care Strategic Issue: How do we optimize use of new and existing health services in county? Background: With mental health parity, how can mental health and physical health sectors

work together better?

The task forces met three to four times each. Read-ahead materials for the first session included the steering committee meeting summaries and a worksheet to frame the strategic issue well enough so that a team of graduate research assistants at Wright State University could identify evidence-based practices in response to the nature of the problem in Madison County. At the second task force meeting, task force members responded to the evidence-based solutions that students presented from their research. This time, the task force members considered the PEARL Test criteria (see above) and determined which solutions would best address the problem. In the case of the Access to Care Task Force, an additional focus group session was conducted to discern where the barriers to health care still stand, given Medicaid expansion in the State of Ohio. That focus group session was held at a food and clothing pantry in London City with frequent customers.

After solutions were selected, the next job of the task forces was to articulate the goals, objectives, and action steps needed to address the strategic issue.

Description of Madison CountyMadison County lies between Springfield and Columbus, and more than one-third of its working population drives 30+ minutes to work. Both I-70 and I-71 go through Madison County. Madison County is primarily a rural county, with over 93% of its land area being cropland, pasture, and forest. About 6% of its land coverage is considered to be urban (that is, residential, commercial, industrial).

Madison County’s total population is 43,053. Its largest community and singular city is London, with 9,896 residents. The village of West Jefferson has a population of 4,217. Outside of those two jurisdictions, most of the population is distributed among townships. Population projections forecast Madison County’s population to increase 10% by the year 2030. The City of London grew by 13% from 2000 to 2010, and therefore, County-level projections appear to be reasonable estimates for London as well. London Correctional Institution and Madison Correctional Institution are located in Madison County; readers should be aware that prison inmates are included in population counts. Madison County is also home to the Ohio Peace Officer Training Academy (OPOTA) and the Ohio Bureau of Criminal Identification & Investigation (BCI).

There are 4,001 households in the City of London and 2,537 family households. About 54% of housing units are owner-occupied and 46% are renter-occupied. In nearly one in five owner-occupied


households, owners are spending more than 35% of their income on housing costs (the recommended percentage is 28%). More than one-third of renters spend more than 35% of their income on housing costs. Of those family households, 29.5% have children under the age of 18 (this is a common proportion). Of households with children, 27% live in female headed households with no male present.

Two-thirds of children who live in poverty are in female headed households (62.7%). In fact, 14.2% of London’s population lives in poverty; among children under the age of 18 the percentage is 18.2%. Among children under the age of 5, the percentage of those living in poverty is estimated to be 45.5%. Among those ages 65 and over, the percentage living in poverty is 4.4%.

Across the entire County, 7,637 people receive food assistance, which is 17.7% of the population and is nearly equivalent to the number that received food assistance last year. The average monthly food assistance payment is $1,014. In terms of cash assistance, the number of households receiving this kind of support has dropped by nearly half from 2012 to 2013 (from 1,612 recipients to 907). Federal law requires that families receiving cash assistance participate in work activities. At least 50% of all able-bodied adults receiving benefits are required to participate in work activities at least 30 hours per week. In two-adult households, at least 90% are required to participate in work activities at least 35 hours per week. In Madison County, the percentage is 81.8% versus 59.5% for Ohio overall.

Nearly 14% of London’s population has no high school diploma. This is higher than the state percentage but lower than the national percentage. Lower educational attainment levels are directly associated with unemployment and lower pay. The percent with a bachelor’s degree or higher is 15.3% versus 24.5% for Ohio and 27.0% for the U.S. Taking into account all workers in London, the median hourly earnings for 6,408 workers are $16.99. More than one-third of jobs (35%) are in food preparation ($9.12), sales ($11.64), and office administration ($14.10). A sustainable wage for a household of two adults in Madison County is $13.15, as long as the person employed is employed full-time. For a household with one adult and one child, a sustainable wage is $17.74.

MAPP Assessment ResultsMadison County completed its community health status report in December of 2013. Three more assessments were completed in February and March of 2014—the Community Themes and Strengths Assessment, the local public health system assessment, and the Forces of Change Assessment. This section presents a synthesis of the forces of change findings which were accomplished via an email survey prior to the first CHIP planning session.

Forces of Change: Recent positive forces that influence the health of Madison County as a whole include the Affordable Care Act and Ohio’s acceptance of Medicaid expansion. Locally, the hospital’s aggressive plan to recruit more primary care physicians, and the hospital’s affiliation with The Ohio State University (OSU) medical system provides an opportunity to reach more County residents in need of healthcare related services. Longer term positive trends that will impact the health of Madison County are that the greater emphasis on wellness and prevention and increased access to health care should result in improved health of the population. Also, the health department levy in 2015, if supported, would allow for a greater number of services to be offered by the health department.


One recent negative force impacting the health of Madison County is that there have been funding cuts at every level of government. Locally, decreased property values reduce the tax base, which funds public health, among other things. Also, due to employers leaving the area, many employees are now losing healthcare benefits. The impact of lost/reduced healthcare benefits was made worse by the harsh winter raising heating bills and increasing costs of gas and food, which result in residents having less money to spend on healthcare services. In the long term, the cost of healthcare is expected to rise further, making it even harder for residents to access health services. Also, an increase in vaccine preventable diseases due to declines in immunizations and the fact that people are living longer is expected to create greater demand for medical care.

Gaps: Crop failure leads to less produce and meat, which results in higher food costs and more food deserts. Also, chemicals in foods contribute to higher incidence of diseases. Regionalizing public health could lead to less personal services and lack of knowledge about how to deliver services in this community. There is a greater need for all types of health care services, mental health, physicians and dentists, than there are providers available in the county. The lower educational attainment and under qualification of the Madison County workforce makes it difficult for unemployed residents to apply for jobs, which leads to less access to medical benefits and a greater need for public health and social services. The effects of the aforementioned gaps to a healthy county are made worse by the state and local political climate, which is in favor of reduced spending on health prevention and social services.

Strengths: The negative effect of internal and external forces on the county’s overall health is mitigated by the strong support for the local health department; it is funded by a local levy, has good capacity and services, and communicates the importance of health to the community. There is also a greater focus on chronic disease prevention and awareness of the need for proper nutrition and exercise, which should lead to better health. There are an increased number of health services offered at Madison Health. Good relationships exist among partnering agencies and the county can build on that connectivity through alignment to a common message of wellness and cultural change. Although some employers have left, there is new industry coming into Madison County; this should help provide additional health benefits to county residents. The county’s proximity to larger metropolitan areas provides access to health resources that are not readily available in the county. Also, parks and recreation assets, green space, widened streets for bicyclists, the fairgrounds and school grounds can all be used to promote exercise, while PAX promotes healthy behaviors and community cohesion.


MAPP Assessments aligned to the Strategic PrioritiesThis next section ties the MAPP assessments to the strategic priorities.

Healthy Lifestyles and Diabetes Education Strategic PriorityForces of Change: The cost of gas and food is increasing. The high cost of healthy food may lead to poor eating habits and increased obesity. There is less cooking occurring as a trend due to how recent generations were raised. Even when fresh foods are available, households need training on how to prepare them. There is a federally designated food desert in the county. Crop failure can lead to less produce and meat, higher food costs, and more food deserts. Chemicals are present in many foods contributing to higher incidence of disease. Incidence of diabetes is higher in the county than in the state and the US. The percentage of the county adult population receiving diabetic screenings is lower than the national benchmark.

Local Public Health System Competencies and Capacities: There are multiple food pantries in the county where residents can go to acquire needed food. The hospital offers diabetes education for anyone with high sugar levels, on diabetic medications, etc. There is a diabetes support group at the Senior Center. The health department’s mission is health promotion and disease prevention.

Gaps: The need for food was identified as the #3 issue among low income households and the #6 for all households, in the household survey conducted for the CHA. Many residents have limited access to healthy foods (4% of the low-income population does not live close to a grocery store). Sixty percent of restaurants in the county are fast-food establishments. Across the entire county, 7,637 people receive food assistance, which is 17.7% of the population and is nearly equivalent to the number that received food assistance last year; however, the dollar amount of support to households has decreased for many in this county due to new federal policy.

Strengths: The local political climate encourages contributions to public health. There is a greater focus on the prevention of chronic diseases in the county. Good relationships exist among partnering agencies (prisons, hospital, departments, DJFS, senior centers). A greater awareness of proper nutrition and exercise should lead to better health. Farmers’ markets provide an opportunity for residents to access fresh produce.

Lung Assessment and Smoking Cessation Strategic PriorityForces of Change: Emergency department diagnoses for COPD and allied conditions have been on the rise from 2010-2012. COPD is consistently among the top 3 inpatient diagnoses. Forty-one percent of county adults have smoked some time in their lifetime and 21% are current smokers, which is higher than the state rate and the national benchmark of 13%. There are air quality issues within the county. The population is aging, leading to a higher rate of pulmonary diseases. There is still a need to affect community norms about smoking, and especially among youth and young adults.


Local Public Health System Competencies and Capacities: Madison Health currently offers a “Heavy Smoker Lung Assessment” to those aged 50-74 who have smoked an average of one pack per day for 30 years (or two packs a day for 15 years).

Gaps: There is currently a tobacco education program in local school districts; however, the materials are outdated. While the hospital’s lung assessment targets the adult population 50-74, there is no program targeting the 18-34 or 35-49 population. There is a need for smoking cessation programs that will target these age groups.

Strengths: The health department employs school nurses, providing a connection to the schools to facilitate tobacco education in the classroom. There are community centers in outlying areas and the senior center in London which act as community gathering spaces which may provide space for cessation classes.

Mental Health Promotion Strategic PriorityForces of Change: Mental health funding is lacking in the county; the levy generates about $300,000 per year, which is not enough to optimize the public mental health system. State funding of mental health services is decreasing. There is a greater need for mental health services in the county than there are providers to care for residents needing care. Obesity can also affect mental health and as sedentary lifestyles become more pervasive, this negatively affects physical and mental health.

Local Public Health System Competencies and Capacities: The PAX program offered in Madison County schools (and in the community at large) will address self-regulation, which is proven to prevent mental health issues down the road. The Free Clinic is pursuing an FQHC relationship with the Rocking Horse Center that could result in more behavioral health services.

Gaps: The Robert Wood Johnson Foundation reports that Madison County has a mental health provider ratio, population to provider, of 10,861:1, while the State’s ratio is 2,553:1.The lack of mental health providers in the county leads to high emergency department admissions for residents presenting with mental health related issues. With few providers available in the county, residents must travel outside the county for services, while transportation has been identified as a barrier to county residents with a need to access care. The emergency department trends show an overall diagnosis discharge rate that has increased by 61.0% from 2010 to 2012 for adult neurotic disorders. County leaders identified mental illness as one of the top 5 major problems facing the county. Low income adults in the county cite adult mental illness as the 3rd of 10 top neighborhood problems. Child emotional and behavioral problems were cited as the 6th top issue among the 10 top neighborhood problems.

Strengths: County residents support the Mental Health Levy. There are many facilities in the county where mental health support could be offered (community centers, senior centers). The Clark, Greene and Madison Counties Respite and Resource Center serves 3-4 children ages 8-24 years suffering from severe mental health related issues for a maximum of 14 days. The hospice Senior Center offers peer support groups throughout the County.


Access to Healthcare Strategic PriorityForces of Change: County residents lack knowledge about health care. Many do not understand Medicaid eligibility or ACA coverage. Medicaid expansion helps those with qualifying incomes, but for those who have a higher income, health care and associated insurance costs continue to soar. For people who still have employer provided health benefits, employers will continue to make employees bear a larger part of the cost. For those with some type of insurance it can still be difficult to access care because there is a lack of providers in the county, and people do not know about or will not use transportation services that are available. The hospital plans to aggressively recruit 2-4 new primary care physicians and is also affiliated with The OSU medical system, which can result in more services being provided in the county.

Local Public Health System Competencies and Capacities: There is one dental office which offers dental care to Medicaid patients. The potential relationship between the Free Clinic and the Rocking Horse Center can lead to more services for Medicaid patients; if the affiliation becomes a reality, it could potentially lead to the offering of dental care. The Free Clinic is not yet an FQHC; under the FQHC “umbrella,” it is possible to expand services to prenatal care, behavioral health care and dental care. A partnership with the FQHC in Springfield (the Rocking Horse Center) may enable the Free Clinic to become a satellite office, thus providing long-term viability and a sufficient number of providers. Higher Medicaid reimbursement rate enables serving the uninsured and full clinic hours. Furthermore, thanks to the Hospital’s recruitment efforts, a PCP group located in London is opening up to Medicaid patients. There will be three new physicians joining in 2014. This group of PCPs is also open to volunteering in the Free Clinic; the Free Clinic has run on 100% physician volunteerism for over a decade.

Gaps: Employees have lost health benefits in response to changes in healthcare laws (ACA). In a survey of Department of Job and Family services customers, the number one need is to address the lack of health insurance that leads to a lack of access to health services. Another major concern is not having a regular doctor or medical home. Transportation is a barrier to accessing healthcare and other needed services.

Strengths: Medicaid expansion in Ohio is one way to increase access to care for the low-income population. The hospital is recruiting more physicians, and the Free Clinic no longer has a waiting list and can provide county residents who have chronic illnesses with medical care. There are many transportation options in the county, but there is little awareness that these options are available.

Priorities SelectedThe task forces were organized in accordance with the four strategic priorities:

1. Healthy Lifestyles and Diabetes Education— How do we improve control of diabetes through education and modify community norms in regard to nutrition and physical activity?

2. Lung Assessment and Smoking Cessation—How do we improve the overall lung health of the population?

3. Mental Health Promotion—How do we remove social barriers to treatment and increase access to mental health services?


4. Access to Care—How do we optimize use of new and existing health services in county?

The Steering Committee had been told from the beginning that identifying three to five priorities rather than ten or twenty priorities would engender success. Therefore, each task force was charged to identify one top priority health issue for the Plan, or to identify strategies that met the PEARL “feasibility” test.

Task forces began their work by reviewing the Community Health Assessments. Task force members reflected on the themes uncovered and then brainstormed the challenges and solution areas. Next, they framed their issue using the worksheet below.

In each task force, many health issues were generated and considered against the same PEARL test decision criteria described earlier. From this effort, top priority issues were defined for each task force. Then Wright State University conducted evidence based practice research to recommend solutions, primarily using the following sources:

• The Guide to Community Preventive Services: http://thecommunityguide.org/index.html• Cochrane Collaboration: http://www.cochrane.org/• Cochrane Public Health Field Review: http://www.vichealth.vic.gov.au/cochrane/• Community Toolbox: http://ctb.ku.edu/en/promisingapproach/databases_best_practices.aspx• Healthy People 2020: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx• National Governor’s Association Center for Best Practices:

http://www.nga.org/portal/site/nga/menuitem.50aeae5ff70b817ae8ebb856a11010a0/• Partnership for Prevention: http://www.prevent.org/• Promising Practices Network: http://www.promisingpractices.net/


• U.S. Preventive Services Taskforce: http://www.ahrq.gov/clinic/uspstfix.htm• Network of Care: http://networkofcare.org


CHIP Implementation Plan

Healthy Lifestyles and Diabetes Education Task Force Goal 1: Provide access to fresh fruit and vegetables to Madison County food pantries.Background: Madison County is a federally designated food desert, meaning that it is a rural area without ready access to fresh, healthy, and affordable food. Instead of supermarkets and grocery stores, the community may rely on fast food restaurants and convenience stores that offer few healthy, affordable food options. The lack of access contributes to a poor diet and can lead to higher levels of obesity and other diet-related diseases, such as diabetes and heart disease.Objective: By December 2014, conduct a fresh fruit and vegetable inventory to establish a baseline for at least one Madison County food pantry. Repeat the inventory annually; increase the amount of fresh fruit and vegetables available in at least one food pantry by 2015.Measures: The task force will create and conduct a fresh produce inventory of one local food pantry in August 2014. The inventory will be repeated annually to determine whether there is an increase in fresh produce availability.

Strategy 1: Offer more fresh produce than the 2014 baseline at one Madison County food pantry by August 2015.Strategy 2: Involve at least one more food pantry in the task force by August 2016; with fresh produce being offered at two or more county food pantries over time.Strategy 3: Explore a partnership between the West Jefferson food pantry and another food pantry located in Madison County; Mid-Ohio Food Bank brings fresh produce to the West Jefferson food pantry that could be used to provide multiple food pantries with fresh food items.Strategy 4: Explore a partnership with the two prisons located in Madison County to provide fruits and vegetables for local food pantries and schools.Strategy 5: Explore partnerships with local farmers to donate produce left over from farmers’ markets.Strategy 6: Explore partnerships with local grocery stores to donate left over food.

Resources: in-kind man hours from partnering agenciesLead Agent: Madison County-London City Health DistrictPartners: Madison County Hospital, Family Council, Miami Valley Child Development Center, and the United Way of Clark, Champaign and Madison CountiesTime Frame: August 2014 establish a baseline

Goal 2: Provide families in Madison County with healthy meals and education about nutrition in a prosocial family atmosphere.Background: The Madison Health is renovating its cafeteria and is positioning that as a community resource as well as a hospital resource. The hospital has already developed the first menu and estimated the cost to be $2.50 per plate. The cafeteria can serve up to 85 people.Objective: By November, 2014, begin providing one community meal per quarter at Madison Health; fill available seating (85 persons) for each meal.Measure: The hospital, Madison Health, will document the number of community residents at the meal.


Strategy 1: Line up sponsors that will fund a meal each quarter.Strategy 2: Coordinate community meals that will be provided at the hospital by inviting families currently being served by county social service agencies.

Resources: Madison Health Foundation/ Rotary Club/ Lion’s Club/ United Way to fund the first meal ($100-$200 from each) while exploring grant fundingLead Agent: Madison HealthPartners: Madison County/London City Health District, Family Council, PAX Community Tool TeamTime Frame: October/November 2014; quarterly thereafter

Goal 3: Package information for the school districts about resources that would allow them to provide healthy snacks to their students throughout the school day.Background: Madison County is a federally designated food desert. The USDA, Department of the Treasury and Department of Health and Human Services have defined a food desert as a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet. Using the census tract as a unit of analysis for identifying food deserts, USDA, Treasury and HHS will give funding priority to projects and interventions that establish healthy food sources in defined food deserts.Objective: By January 2015 compile Information regarding the USDA Fresh Fruit and Vegetable Program (FFVP) and how to apply for FFVP funding; present the information to the Madison County Schools Superintendents as a way to increase the fruit and vegetable intake of Madison County students.Measure: The Task Force will recruit school nurses to present the USDA FFVP to school superintendents in 2015 at the joint meeting of school superintendents.

Strategy 1: Provide guidance about applying for grant funding through the federal Fresh Fruit and Vegetable Program.1

Strategy 2: Recruit school nurses to make the presentation to the school superintendents.Resources: in-kind man hours from partnering agencies Partners: Healthy Lifestyles Task Force Member Agencies and School NursesTime Frame: January 2015

Goal 4: More people access local nutrition education services rather than going out of the county.Background: Childhood obesity is consistently a singular diagnosis among children in Madison County. While the hospital’s diabetes education program is well attended, many residents, parents and social /human service agencies are not aware of the hospital’s individual nutrition counselling services. As a result, in one instance, parents drive their children to Children’s Hospital outside of the county to obtain such services.Objective: By December, 2015, increase participation in Madison Health’s individual nutrition education program by 2%.Measure: Madison Health will track and report the number of adults and children obtaining services from their individual nutrition education programs. The number will be reported to the Family Council three times a year.

Strategy 1: Present the hospital’s nutrition counselling program at Family Council meetings.

1 Evidence based practice


Strategy 2: Promote awareness of the availability of individual nutrition counselling for children (promotion will also take place via the WIC program).Strategy 3: Cross-market the diabetes education program with other hospital departments and county agencies.Strategy 4: Promote individual nutrition counselling through Primary Care Physicians. Medical Nutrition Therapy is covered by insurance as a preventive measure for multiple health related problems but must have a doctor’s referral.

Resources: community networking; existing hospital marketing resourcesLead Agent: Madison HealthPartners: Family Council, Chamber of Commerce, School Nurses, WIC, Madison County-London City Health DistrictTime Frame: ongoing

Lung Assessment and Smoking Cessation Task Force Goal 1: Promote the Madison Health Lung Assessment to those ages 50 to 74.Background: Madison Health provides low-dose CT lung screening for those at high risk for lung disease or lung cancer. Those at highest risk are smokers who have a 30-pack a year history, which is either a pack a day for 30 years or two packs a day for 15 years.Objective: Increase the number of people obtaining a lung assessment who are at risk for lung disease or lung cancer by 2% annually by promoting the lung assessment services available in the County.Measure: Madison Health will regularly report the number of people seeking lung assessments.

Strategy 1: Place a lung cancer risk assessment tool on the hospital’s website to guide people at highest risk to obtain a lung assessment. One such assessment tool is provided by the American Lung Association: http://lungcancerscreeningsaveslives.org/#homeStrategy 2: Continue to place advertisements in the newspaper, on printed bags including seeking a partnership with pharmacies to print information on prescription medication bags, and use other media.Strategy 3: Institute a new local health department survey that asks all clients of clinics, those who come in to pick up birth certificates, etc.: Do you currently smoke cigarettes; if yes, have you smoked a pack a day for 30 years or two packs a day for 15 years (if yes, promote the lung assessment); would you like help in stopping? The survey may include questions about exposure to second hand smoke.Strategy 4: Seek partnerships with doctors’ offices to distribute information about the lung assessment offered by Madison Health.

Resources: Madison Health has invested in the necessary equipment and the advertising. The Health Department will create the tobacco use survey.Lead Agent: Madison Health, social/human service agenciesPartners: Madison County-London City Health District, and pursue pharmacies and doctors’ offices as additional partners.Time Frame: Ongoing


Goal 2: Provide early education to prevent tobacco use.Background: Nearly all tobacco use begins in childhood and adolescence. In all, 88% of adult cigarette smokers who smoke daily, report that they started smoking by the age of 18 (NSDUH 2010, Chapter 3). According to the Surgeon General’s 2012 report, “…school-based programs and policies are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults” when accompanied by policy change, price increases, and other community-based efforts.Objective: By August 2015, implement tobacco education programs targeting Madison County third graders in Madison County schools. Measure: School Nurses will report to Madison County/London City Health District at least one time per year the number of grade schools whose third graders receive tobacco education programs.

Strategy 1: Use evidence-based programs such as Tar Wars2 for the delivery of tobacco use prevention programs in elementary schools. Obtain free materials through the American Lung Association where possible.Strategy 2: Use school nurses as the means of delivering this education; school nurses are funded by the schools through contracts with the local health department. Strategy 3: Strengthen a partnership with Cedarville University’s nursing program to assist in delivering the tobacco use prevention program.

Resources: Madison Health has invested in the necessary equipment and the advertising. The Health Department will create the tobacco use survey.Lead Agent: Madison HealthPartners: Madison County-London City Health District, and pursue pharmacies and doctors’ offices as additional partners.Time Frame: Ongoing

Goal 3: Decrease tobacco use among Madison County teens and adults.Background: According to the CDC tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Although the health benefits are greater for people who stop at earlier ages, quitting is beneficial at all ages.Objective: By 2017, decrease the percentage of adults who smoke by1-2% of Madison County adults. And by 2017, decrease the percentage of teens who smoke by 1-2%.Measure: Madison County/London City Health District will track the number of adults who smoke and the number who request support in stopping via a new survey the Health Department will use in house. The number of teens who smoke will be tracked via the Youth Risk Behavior Survey which is conducted in Madison County every two years. Data collection is underway in December 2014, and therefore a baseline number and percentage will be available in early 2015.

Strategy 1: Identify adults who want help to quit smoking via a survey distributed by the local health department. The survey will ask all clients of clinics, those who come in to pick up birth certificates, etc.: Do you currently smoke cigarettes?; Would you like help in stopping?

2 Evidence based practice


Strategy 2: Continue Mommy & Me,3 a smoking cessation program carried out at Madison Health that educates pregnant women about the effects of smoking while pregnant and provides smoking cessation support to expectant mothers.Strategy 3: Promote online smoking cessation programs while the community seeks resources to provide cohort-specific, evidence-based cessation programs. For example, guide women in the WIC program who indicate they want to quit smoking to online resources.

Smokefree Teen: Provides information on dealing with social changes related to quitting smoking, how smoking affects your health and provides support options; http://teen.smokefree.gov/ 4

Freedom From Smoking Online: adult-targeted smoking cessation program that gives information about preparing to quit, then guide participants through their Quit Day and the first few weeks of being smoke free; http://www.ffsonline.org/ 5

Strategy 4: Obtain information from Knox County Health Department about their smoking cessation program and how they resource it.Strategy 5: Obtain resources to implement a county-wide smoking cessation initiative via county and state level grants.

• Carry out a smoking cessation program and provide materials targeted to residents who are ages 50 to 74 as a high priority to meet the needs of adults who receive the hospital’s lung assessment and who would like to quit smoking.

• Deliver a smoking cessation program targeting adults younger than 50 years of age that provides cessation counselling and nicotine replacement therapy.

• Carry out a smoking cessation program targeting teens, such as Not On Tobacco (NOT).6

Resources: Online tools will be used until grant resources are obtainedLead Agent: Madison County-London City Health DistrictPartners: Madison Health, schools, businesses/business associations, pharmacies, physicians Time Frame: Begin in 2014

Mental Health Promotion Task Force Goal 1: Increase utilization of mental health services by reducing the stigma related to mental health issuesBackground: A slightly higher percentage of adults in Madison County reported that they had poor mental health days in the month prior to the Behavioral Risk Factor Surveillance Survey versus the percentage for Ohio and the U.S. (4.2%, 3.8%, and 2.3%, respectively). Also, adult mental illness was identified as the third highest neighborhood problem by low-income residents responding to the Community Needs Assessment survey, and key informant interviews identified adult mental illness as one of the main problems facing Madison County as a whole. There are mental health services available to those county residents needing mental health services; however, many of those in need do not take

3 Evidence based practice4 Evidence based practice5 Ibid6 Ibid


http://www.ffsonline.org/

http://teen.smokefree.gov/

advantage of these services. The stigma associate with mental health services leads to a lack of understanding by family, friends, and co-workers causing many people affected by mental health related issues to be reluctant about seeking help or treatment.Objective: By December 2015, complete training of Madison County social service agencies, school counselors, vice principals, bus drivers, etc. in Mental Health First Aid.7

Measure: The Mental Health & Recovery Board of Clark, Greene & Madison Counties will document and report the number of professionals that attend the Mental Health First Aid training to the Family Council by the end of 2015.

Strategy 1: Provide Mental Health First Aid 8training to Madison County social service agencies, school counselors, vice principals bus drivers, etc.

Resources: Mental Health & Recovery Board of Clark, Greene & Madison Counties has funding available to provide trainingLead Agent: Madison County Depression and Suicide Prevention CoalitionPartners: Mental Health & Recovery Board of Clark, Greene & Madison CountiesTime Frame: 2015

Goal 2: Increase student access to school based mental health servicesBackground: Childhood emotional and behavioral problems was listed as one of the top ten neighborhood problems by residents responding to the Community Needs Assessment survey. Also, children’s mental health services were identified by key informants as one of the additional services that are needed in Madison County. Schools provide one point of access to mental health services for children suffering from mental health related issues; however, in Madison County there is only one school guidance counselor that provides mental health services for all Madison County schools. The majority of the counselor’s time is spent with those students with the most severe mental health needs, which leaves little time for other students to take advantage of counselling services. Objective: By June 2015, complete an assessment of Madison County Schools’ readiness to implement Telemental health services. 9 Services may be implemented as schools become ready to implement the program and funds are available.Measure: The London City School District will report the results of their assessment on the feasibility of telemental health services to the Mental Health Promotion Task Force in June 2015.

Strategy 1: Explore implementation of Telemental health services in Madison County schoolsStrategy 2: Assess readiness and capacity of Madison County schools to implement Telemental health servicesStrategy 3: Explore SAMHSA “Now is the Time” Project AWARE Local Educational Agency Grant to fund development and maintenance of Telemental health services Resources: explore grant funding

Lead Agent: Madison County SchoolsPartners: Mental Health & Recovery Board of Clark, Greene & Madison Counties, Mental Health Services for Clark and Madison Counties

7 Evidence based practice8 Evidence based practice9 Evidence based practice


Time Frame: assess readiness by June 2015

Access to Care Task ForceGoal 1: Increase awareness of health related services available in the county.Background: The Madison County Board of Developmental Disabilities operates the Madison Ride Program, which benefits the community as a whole. The service is used by a multitude of Madison County residents, through collaboration with Madison County Job and Family Services, Veteran’s Administration, and other community agencies as well as on a private pay basis. A focus group with participants of Help House, which provides food, clothing, shelter, and emergency assistance, uncovered that none of the participants use Madison Ride even though all of them have critical transportation needs. None of the participants knew that if they had Medicaid, it may pay for their transportation to healthcare providers. Participants also thought that they had to have a job in order to enroll in Medicaid under the new Affordable Care Act; their impression was that “for the unemployed, no health insurance is available.” Others were trying to pursue disability but they don’t know any local doctors who could assist them with that process. One participant said that she completed forms to be eligible for the Free Clinic, but was told she didn’t qualify. Instead “I was given a $20 voucher to put toward a $500 prescription for my diabetes. I’m just not taking my meds because I can’t afford them.” Furthermore, participants were afraid to enroll in SNAP to obtain food stamps; they had been told that they could lose their unemployment benefits if they sought food stamps. Others described “84 year old neighbors who now get $14 per month in food stamps. I’m not risking my unemployment for $14 a month.” Objective: By June 2015, promote healthcare resources among the community and specific populations with significant barriers to accessing health care through at least two different methods of communication or distribution.Measure: The Access to Care Task Force will report their communication activities every four months to Family Council.

Strategy 1: Advertise the health care providers who serve populations with significant barriers to accessing health care at the HELP House and at other food pantries; the providers should make presentations to the directors of the pantries to increase awareness of their capacity. Given Medicaid expansion, there have been significant changes in health care delivery that must be communicated. Strategy 2: Raise awareness of transportation services that are currently available in the county.Strategy 3: Explore development of a Human Services Transportation Coordination Plan, which would make the county eligible for federal transportation funding.

Resources: Health Care provider’s advertising; co-advertise the Madison County Ride with health care information; use the share point to clarify transportation services so that county agencies can share this information with their clientsLead Agent: Health care providersPartners: Free Clinic, MCDJFS, Madison County/London City Health District, Madison HealthTime Frame: Ongoing


Goal 2: Increase residents’ understanding of preventive health services, the preventive health related services that are available in the county and how to access themBackground: Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. While all patients are at risk for health literacy challenges, some population groups are more predisposed to communication barriers, specifically those with lower educational attainment, those of older age older age (especially over 65), and non-native English speakers. According to the US Department of Health and Human Services, health literacy not only affects people’s ability to navigate the healthcare system and engage in self-care and chronic disease management, but also those with poor health literacy often lack knowledge or have misinformation about the body as well as the nature and causes of disease. Without this knowledge, they may not understand the relationship between lifestyle factors such as diet and exercise and various health outcomes.Objective: Implement at least one activity which increases the health literacy of patients and improve communication between patients and health care providers by June 2015.Measure: The Access to Care Task Force will report their communication activities every four months to Family Council.

Strategy 1: Promote health literacy onlineResources: Network of Care website via the Madison County-London City Health DistrictLead Agent: Madison County-London City Health DistrictPartners: Madison HealthTime Frame: 2015

Strategy 2: Develop opportunities for face-to-face provider/patient encounters for increased understanding of preventive health services available.Resources: Madison Health’s Physician Relations LiaisonPartners: Madison Health, Madison County/London City Health District, health care providersTime Frame: Ongoing

Goal 3: Assure prompt response to emergency department patients exhibiting symptoms of mental health related issuesBackground: Due to many residents lacking a medical home and the shortage of mental health providers in the county, many residents presenting critical mental health related issues seek treatment in the hospital’s emergency department. The emergency department trends show an overall diagnosis discharge rate that has increased by 61.0% from 2010 to 2012 for adult neurotic disorders. Once patients have arrived at the emergency department, they often experience long wait times before being seen by a mental health professional. Objective: By 2016, develop a partnership with OSU to explore provide telepsychiatry services to ED patients. By 2017, construct an ED safe room for patients presenting with symptoms of mental illness.Measure: The Hospital, Madison Health, will report its progress on its Ohio State University partnership and on the construction of its Emergency Department every four months to the Access to Care Task Force and then to Family Council.


Strategy 1: Explore a telepsychiatry10 partnership with Ohio State UniversityStrategy 2: Include a safe room11 for psychiatric patients in the plans for a new Emergency Department

Resources: Madison Health’s existing partnership with The OSU and its investment in a new EDLead Agent: Madison HealthPartners: Mental Health and Recovery Board along with the Mental Health Task ForceTime Frame: 2016/2017

Goal 4: Provide excellent customer service to all current and prospective clients receiving services from county agenciesBackground: Through anecdotal evidence it has been found that some residents who are in need of services have difficulty being connected to the correct service. They may be referred to multiple agencies before being placed in contact with the correct agency or agency staff may be unable to provide clients with helpful information. This may lead to residents being reticent in contacting agencies a second time, and subsequently not accessing the services they need.Objective: By December 2015, provide at least one customer service training to Madison Health and county agency staff; repeat the training annually thereafter.Measure: Madison Health will make their customer service training available to county agencies and will report out the training evaluation results to the Access to Care Task Force and then to Family Council on an annual basis.

Strategy 1: Pool agency resources to provide group customer service training.Strategy 2: Align hospital staff retraining with community health improvement goals.

Resources: Training dollars in agency budgetsLead Agent: Madison HealthPartners: Multiple agenciesTime Frame: Annually beginning in 2015

10 Evidence based practice11 Evidence based practice


Sustainability: CHIP Monitoring and Public Involvement

Sustaining implementation efforts of the Community Health Improvement Plan as well as ongoing participation in the community health improvement process is addressed below.

1. Sustainability is woven into the plan primarily by aligning strategic partners to a community health improvement agenda. Involving partners with substantial resources such as higher education partners and the hospital infuses student interns, research and evidence based practice knowledge, and foundation support among other supports. Hospital support is reinforced via their own IRS required Community Health Needs Assessment and Implementation strategy.

2. During the creation of the plan, significant efforts were made to keep the strategies and actions doable and manageable with today’s resources. Generally, the strategies are not dependent upon applying for and being awarded grants, or other uncertain resources.

3. Commitments of substantial resources, such as adding new personnel, have been verified by public commitment and recruitment efforts being already underway.

4. Madison County-London City Health District is committed to convening strategic partners quarterly in the first year and annually during the planning cycle so that annual progress reports can be reported in multi-agency type meetings such as the Madison County Family and Children First Council meetings. The health department is also committed to repeating this process every five years.


Appendix A: Implementation MatrixThe following goals and strategies are organized according to the four strategic areas.

Strategic Issue: Healthy Lifestyles and Diabetes EducationGoal 1: Provide access to fresh fruit and vegetables to Madison County food pantries.Background: Madison County is a federally designated food desert, meaning that it is a rural area without ready access to fresh, healthy, and affordable food. Instead of supermarkets and grocery stores, the community may rely on fast food restaurants and convenience stores that offer few healthy, affordable food options. The lack of access contributes to a poor diet and can lead to higher levels of obesity and other diet-related diseases, such as diabetes and heart disease.Objective: Increase the amount of fresh fruit and vegetables that are available at local food pantries.Measures: Create and conduct a fresh produce inventory of one local food pantry in August 2014. Repeat the inventory annually to determine whether there is an increase in fresh produce availability.Strategy 1: Offer more fresh produce than the 2014 baseline at one Madison County food pantry by August 2015.Strategy 2: Involve at least one more food pantry in the task force by August 2016; with fresh produce being offered at two or more County food pantries over time.Strategy 3: Explore a partnership between the West Jefferson food pantry and another food pantry located in Madison County; Mid-Ohio Food Bank brings fresh produce to the West Jefferson food pantry that could be used to provide multiple food pantries with fresh food items.Strategy 4: Explore a partnership with the two prisons located in Madison County to provide fruits and vegetables for local food pantries and schools.Strategy 5: Explore partnerships with local farmers to donate produce left over from farmers’ markets.Strategy 6: Explore partnerships with local grocery stores to donate left over food.Resources: in-kind man hours from partnering agenciesLead Agent: Madison County-London City Health DistrictPartners: Madison Health, Family Council, Miami Valley Child Development Center, and the United Way of Clark, Champaign and Madison CountiesTime Frame: August 2014 establish a baselineGoal 2: Provide families in Madison County with healthy meals and education about nutrition in a prosocial family atmosphere.Background: Madison Health is renovating its cafeteria and is positioning that as a community resource as well as a hospital resource. The hospital has already developed the first menu and estimated the cost to be $2.50 per plate. The cafeteria can serve up to 85 people.Objective: Provide a quarterly community meal at the hospital to educate families about healthy eating and expose residents to new fruits, vegetables, etc.Strategy 1: Line up sponsors that will fund a meal each quarter.Strategy 2: Coordinate community meals that will be provided at the hospital by inviting families currently being served by county social service agencies.Resources: Madison Health Foundation/ Rotary Club/ Lion’s Club/ United Way to fund the first meal ($100-$200 from each) while exploring grant fundingLead Agent: Madison HealthPartners: Madison County/London City Health District, Family Council, PAX Community Tool TeamTime Frame: October/November 2014; quarterly thereafter


Goal 3: Package information for the school districts about resources that would allow them to provide healthy snacks to their students throughout the school day.Background: Madison County is a federally designated food desert. The USDA, Department of the Treasury and Department of Health and Human Services have defined a food desert as a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet. Using the census tract as a unit of analysis for identifying food deserts, USDA, Treasury and HHS will give funding priority to projects and interventions that establish healthy food sources in defined food deserts.Objective: Present information at the Superintendents’ meeting in January 2015.Strategy 1: Provide guidance about applying for grant funding through the federal Fresh Fruit and Vegetable Program.Strategy 2: Recruit school nurses to make the presentation to the school Superintendents.Resources: in-kind man hours from partnering agenciesPartners: Healthy Lifestyles Task Force Member Agencies and School NursesTime Frame: January 2015Goal 4: More people access local nutrition education services rather than going out of the County.Background: Childhood obesity is consistently a singular diagnosis among children in Madison County. While the Hospital’s diabetes education program is well attended, many residents, parents and social /human service agencies are not aware of the hospital’s individual nutrition counselling services. As a result in one instance, parents drive their children to children’s hospitals outside of the county to obtain such services.Objective: More residents take advantage of Madison Health’s individual nutrition counselling services.Strategy 1: Present the hospital’s nutrition counselling program at Family Council meetings.Strategy 2: Promote awareness of the availability of individual nutrition counselling for children (promotion will also take place via the WIC program).Strategy 3: Cross-market the diabetes education program with other hospital departments and county agencies.Strategy 4: Promote individual nutrition counselling through primary care physicians. Medical nutrition therapy is covered by insurance as a preventive measure for multiple health related problems but must have a doctor’s referral.Resources: community networking; existing hospital marketing resourcesLead Agent: Madison HealthPartners: Family Council, Chamber of Commerce, School Nurses, WIC, Madison County-London City Health DistrictTime Frame: ongoing


Strategic Issue: Lung Assessment and Smoking CessationGoal 1: Promote the Madison Health Lung Assessment to those ages 50 to 74.Background: Madison Health provides low-dose CT lung screening for those at high risk for lung disease or lung cancer. Those at highest risk are smokers who have a 30-pack a year history, which is either a pack a day for 30 years or two packs a day for 15 years.Objective: Increase the number of people at risk for lung disease or lung cancer obtaining a lung assessment by 2% annually.Strategy 1: Place a lung cancer risk assessment tool on the hospital’s website to guide people at highest risk to obtain a lung assessment. One such assessment tool is provided by the American Lung Association: http://lungcancerscreeningsaveslives.org/#homeStrategy 2: Continue to place advertisements in the newspaper, on printed bags including seeking a partnership with pharmacies to print information on prescription medication bags, and use other media.Strategy 3: Institute a new local health department survey that asks all clients of clinics, those who come in to pick up birth certificates, etc.: Do you currently smoke cigarettes; if yes, have you smoked a pack a day for 30 years or two packs a day for 15 years (if yes, promote the lung assessment); would you like help in stopping? The survey may include questions about exposure to second hand smoke.Strategy 4: Seek partnerships with doctors’ offices to distribute information about the lung assessment offered by Madison Health..Resources: Madison Health has invested in the necessary equipment and the advertising. The health department will create the tobacco use survey.Lead Agent: Madison Health, social/human service agenciesPartners: Madison County-London City Health District, and pursue pharmacies and doctors’ offices as additional partners.Time Frame: OngoingGoal 2: Provide early education to prevent tobacco use.Background: Nearly all tobacco use begins in childhood and adolescence. In all, 88% of adult cigarette smokers who smoke daily, report that they started smoking by the age of 18 (NSDUH 2010, Chapter 3). According to the Surgeon General’s 2012 report, “…school-based programs and policies are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults” when accompanied by policy change, price increases, and other community-based efforts.Objective: Deliver updated tobacco use prevention education and materials to elementary school students.Strategy 1: Use evidence-based programs such as Tar Wars for the delivery of tobacco use prevention programs in elementary schools. Obtain free materials through the American Lung Association where possible.Strategy 2: Use school nurses as the means of delivering this education; school nurses are funded by the schools through a contract with the local health department.Strategy 3: Strengthen a partnership with Cedarville University’s nursing program to assist in delivering the tobacco use prevention program.Resources: Madison Health has invested in the necessary equipment and the advertising. The health department will create the tobacco use survey.Lead Agent: Madison HealthPartners: Madison County-London City Health District, and pursue pharmacies and doctors’ offices as additional partners.


http://lungcancerscreeningsaveslives.org/#home

Time Frame: OngoingGoal 3: Decrease tobacco use among Madison County teens and adults.Background: According to the CDC tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Although the health benefits are greater for people who stop at earlier ages, quitting is beneficial at all ages.Objective: By 2017, decrease the percentage of adults who smoke from 21% to 19% of Madison County adults.Strategy 1: Identify adults who want help to quit smoking via a survey distributed by the local health department. The survey will ask all clients of clinics, those who come in to pick up birth certificates, etc.: Do you currently smoke cigarettes; would you like help in stopping?Strategy 2: Continue Mommy & Me, a smoking cessation program carried out at Madison Health that educates pregnant women about the effects of smoking while pregnant and provides smoking cessation support to expectant mothers.Strategy 3: Promote online smoking cessation programs while the community seeks resources to provide cohort-specific, evidence-based cessation programs. For example, guide women in the WIC program who indicate they want to quit smoking to online resources.

Smokefree Teen: Provides information on dealing with social changes related to quitting smoking, how smoking affects your health and provides support options; http://teen.smokefree.gov/

Freedom From Smoking Online: adult-targeted smoking cessation program that gives information about preparing to quit, then guide participants through their Quit Day and the first few weeks of being smoke free; http://www.ffsonline.org/

Strategy 4: Obtain information from Knox County Health Department about their smoking cessation program and how they resource it.Strategy 5: Obtain resources to implement a county-wide smoking cessation initiative via county and state level grants.

Carry out a smoking cessation program and provide materials targeted to residents who are ages 50 to 74 as a high priority to meet the needs of adults who receive the hospital’s lung assessment and who would like to quit smoking.

Deliver a smoking cessation program targeting adults younger than 50 years of age that provides cessation counselling and nicotine replacement therapy.

Carry out a smoking cessation program targeting teens, such as Not On Tobacco (NOT).Resources: Online tools will be used until grant resources are obtainedLead Agent: Madison County-London City Health DistrictPartners: Madison Health, schools, businesses/business associations, pharmacies, physiciansTime Frame: Begin in 2014


http://www.ffsonline.org/

http://teen.smokefree.gov/

Strategic Issue: Mental HealthGoal 1: Increase utilization of mental health services by reducing the stigma related to mental health issuesBackground: A slightly higher percentage of adults in Madison County reported that they had poor mental health days in the month prior to the Behavioral Risk Factor Surveillance Survey versus the percentage for Ohio and the U.S. (4.2%, 3.8%, and 2.3%, respectively). Also, adult mental illness was identified as the third highest neighborhood problem by low-income residents responding to the Community Needs Assessment survey, and key informant interviews identified adult mental illness as one of the main problems facing Madison County as a whole. There are mental health services available to those county residents needing mental health services; however, many of those in need do not take advantage of these services. The stigma associated with mental health services leads to a lack of understanding by family, friends, and co-workers causing many people affected by mental health related issues to be reluctant about seeking help or treatment.Objective: Improve the community’s knowledge and modify perception of mental health and related issuesStrategy 1: Provide Mental Health First Aid training to Madison County social service agencies, school counselors, vice principals bus drivers, etc.Resources: Mental Health & Recovery Board of Clark, Greene & Madison Counties has funding available to provide trainingLead Agent: Madison County Depression and Suicide Prevention CoalitionPartners: Mental Health & Recovery Board of Clark, Greene & Madison CountiesTime Frame: 2015Goal 2: Increase student access to school based mental health servicesBackground: Childhood emotional and behavioral problems was listed as one of the top ten neighborhood problems by residents responding to the Community Needs Assessment survey. Also, Children’s mental health services were identified by key informants as one of the additional services that are needed in Madison County. Schools provide one point of access to mental health services for children suffering from mental health related issues; however, in Madison County there is only one school guidance counselor that provides mental health services for all Madison County schools. The majority of the counselor’s time is spent with those students with the most severe mental health needs, which leaves little time for other students to take advantage of counseling services.Objective: Provide telemental health services in at least one Madison County SchoolStrategy 1: Explore implementation of Telemental health services in Madison County schoolsStrategy 2: Assess readiness and capacity of Madison County schools to implement Telemental health servicesStrategy 3: Explore SAMHSA “Now is the Time” Project AWARE Local Educational Agency Grant to fund development and maintenance of telemental health servicesResources: explore grant fundingLead Agent: Madison County SchoolsPartners: Mental Health & Recovery Board of Clark, Greene & Madison Counties, Mental Health Services for Clark and Madison CountiesTime Frame: assess readiness by June 2015


Strategic Issue: Access to CareGoal 1: Increase access to health related servicesBackground: Background: The Madison County Board of Developmental Disabilities operates the Madison Ride Program, which benefits the community as a whole. The service is used by a multitude of Madison County residents, through collaboration with Madison County Job and Family Services, Veteran’s Administration, and other community agencies as well as on a private pay basis. A focus group with participants of Help House, which provides food, clothing, shelter, and emergency assistance, uncovered that none of the participants use Madison Ride even though all of them have critical transportation needs. None of the participants knew that, if they had Medicaid, that it may pay for their transportation to healthcare providers. Participants also thought that they had to have a job in order to enroll in Medicaid under the new Affordable Care Act; their impression was that “for the unemployed, no health insurance is available.” Others were trying to pursue disability but they don’t know any local doctors who could assist them with that process. One participant said that she completed forms to be eligible for the Free Clinic, but was told she didn’t qualify. Instead “I was given a $20 voucher to put toward a $500 prescription for my diabetes. I’m just not taking my meds because I can’t afford them.” Furthermore, participants were afraid to enroll in SNAP to obtain food stamps; they had been told that they could lose their unemployment benefits if they sought food stamps. Others described “84 year old neighbors who now get $14 per month in food stamps. I’m not risking my unemployment for $14 a month.”Objective: By June 2015, promote healthcare resources among the community and specific populations with significant barriers to accessing health care through at least two different methods of communication or distribution.Strategy 1: Advertise the health care providers who serve populations with significant barriers to accessing health care at the HELP House and at other food pantries; the providers should make presentations to the directors of the pantries to increase awareness of their capacity. Given Medicaid expansion, there have been significant changes in health care delivery that must be communicated.Strategy 2: Raise awareness of transportation services that are currently available in the county.Strategy 3: Explore development of a Human Services Transportation Coordination Plan, which would make the county eligible for federal transportation funding.Resources: Health Care provider’s advertising; co-advertise the Madison County Ride with health care information; use the share point to clarify transportation services so that county agencies can share this information with their clientsLead Agent: Health care providersTime Frame: OngoingGoal 2: Increase residents’ understanding of preventive health services, what health related services are available in the county and how to access themBackground: Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. While all patients are at risk for health literacy challenges, some population groups are more predisposed to communication barriers, specifically those with lower educational attainment, those of older age older age (especially over 65), and non-native English speakers. According to the US Department of Health and Human Services, health literacy not only affects people’s ability to navigate the healthcare system and engage in self-care and chronic disease management, but also those with poor health literacy often lack knowledge or have misinformation about the body as well as the nature and causes of disease. Without this knowledge, they may not understand the relationship between lifestyle factors such as diet and exercise and various health outcomes.Objective: Raise awareness of health related topics and empower marginalized populations to take


part in their healthcareStrategy 1: Promote health literacy onlineResources: Network of Care website via the Madison County-London City Health DistrictLead Agent: Madison County-London City Health DistrictPartners: Madison HealthTime Frame: 2015Strategy 2: Develop opportunities for face-to-face provider/patient encounters for increased understanding of preventive health services available.Resources: Madison Health’s Physician Relations LiaisonPartners: Madison Health, Madison County/London City Health District, health care providersTime Frame: Ongoing______________________________________________________________________________________

Goal 3: Assure prompt response to emergency department patients exhibiting symptoms of mental health related issuesBackground: Due to many residents lacking a medical home and the shortage of mental health providers in the County, many residents presenting critical mental health related issues seek treatment in the hospital’s emergency department. The emergency department trends show an overall diagnosis discharge rate that has increased by 61.0% from 2010 to 2012 for adult neurotic disorders. Once patients have arrived at the emergency department, they often experience long wait times before being seen by a mental health professional.Objective: Improve services to psychiatric patients that present in the emergency department.Strategy 1: Explore telepsychiatry partnership with Ohio State UniversityStrategy 2: Include a safe room for psychiatric patients in the plans for a new emergency departmentResources: Madison Health’s existing partnership with The OSU and its investment in a new EDLead Agent: Madison HealthPartners: Mental Health and Recovery Board along with the Mental Health Task ForceTime Frame: 2016/2017Goal 4: Provide excellent customer service to all current and prospective clients receiving services from county agenciesBackground: Through anecdotal evidence it has been found that some residents who are in need of services have difficulty being connected to the correct service. They may be referred to multiple agencies before being placed in contact with the correct agency or agency staff may be unable to provide clients with helpful information. This may lead to residents being reticent in contacting agencies a second time, and subsequently not accessing the services they need.Objective: Improve client communication across agencies so that there is no wrong door, thus improving customer satisfaction across agencies.Strategy 1: Pool agency resources to provide group customer service training.Strategy 2: Align hospital staff retraining with community health improvement goals.Resources: Training dollars in agency budgetsLead Agent: Madison HealthPartners: Multiple agenciesTime Frame: Annually beginning in 2015


Appendix B: Alignment with State & National PrioritiesThe following table shows how the strategic issues addressed in the Madison County CHIP align with State and National priorities.

Strategic Issue Ohio’s State Health Improvement Plan

Healthy People 2020

National Prevention Strategy (NPS)

Healthy Lifestyles and Diabetes Education: provide residents with greater access to healthy foods and nutrition education.

Preventing and reducing chronic disease risk factors associated with tobacco use, poor nutrition and lack of physical activity is the foundation for a healthy, competitive and prosperous state.

NWS-14 Increase the contribution of fruits to the diets of the population aged 2 years and olderNWS-15 Increase the variety and contribution of vegetables to the diets of the population aged 2 years and older

Increase access to healthy and affordable foods in communities and help people recognize and make healthy food and beverage choices are NPS recommendations.

Lung Assessment and Smoking Cessation: increase at-risk lung assessments, provide tobacco education to elementary-aged students; provide smoking cessations programs targeting specific age groups.

Healthy Ohio Tobacco Use Prevention and Cessation Program aims to:1. Prevent youth tobacco-use initiation2. Promote cessation of tobacco use3. Eliminate secondhand smoke exposure for all Ohioans4. Eliminate disparities among populations affected by tobacco use

TU-3 Reduce the initiation of tobacco use among children, adolescents, and young adultsTU-1.1 Reduce cigarette smoking by adultsTU-4 Increase smoking cessation attempts by adult smokersTU-5 Increase recent smoking cessation success by adult smokers

Teach children about the health risks of smoking and implement evidence-based recommendations for tobacco use treatment and provide information to patients on the health effects of tobacco use and secondhand smoke exposure are NPS strategies.

Mental Health: reduce stigma and increase knowledge of mental health related issues; increase school-based mental health services

Mental Health is addressed as a priority by the Ohio Department of Health, the Ohio Department of Job & Family Services, and Ohio Department of Mental Health

MHMD-4 Reduce the proportion of persons who experience major depressive episodes (MDEs)MHMD-6 Increase the proportion of children with mental health problems who receive treatment Increase the proportion of children with mental

Training key community members (e.g.,adults who work with the older adults,youth, and armed services personnel)to identify the signs of depression andsuicide and refer people to resources and ensuring students have access to


health problems who receive treatmentMHMD-9 Increase the proportion of adults with mental health disorders who receive treatment

comprehensive health services, including mental health and counseling services in schools are NPS strategies.

Access to Care: raise awareness of transportation options available to take residents to medical appointment; empower residents to take part in their medical care; provide prompt service to ED mental health patients

The Ohio Department of Health is committed to assuring Ohioans have access to quality health care

AHS-5 Increase the proportion of persons who have a specific source of ongoing careAHS-6 Reduce the proportion of persons who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines

Reduce disparities in access to quality health care is an NPS recommendation. Help ensure that prevention strategies are culturally, linguistically, and age appropriate, and that they match people’s health literacy skills is an NPS strategy.


Appendix C

TASK FORCES

Access to Healthcare

Akers, Julie Madison Health

Baynes, Pat Madison County Senior Center

Canney, Melissa Madison County Health Partners Free Clinic

Dodge-Dorsey, Lori Madison County Department of Job and Family Services

Herman, Jane Bluebird Retirement Community

Peters, Chris Madison Health

Stout, Cindy (Chair) Madison Health

Webb, Mary Ann Madison County/London City Health District

Young, Susan Madison County/London City Health District

Healthy Lifestyles/Food Security

Baldwin, Sherry Family Council

Comer, Lexi (Chair) Madison County/London City Health District

Husek, Kathy Madison County/London City Health District

Hyden, Susie Madison County/London City Health District

Lane, Bridget Madison County/London City Health District

Renz, Darren Madison Health

Thomas, Lori Madison County Department of Family and Children

Wilson, James Madison Health


Mental Health

Lentz, Pat Madison County/London City Health District

Michaelson, Jennifer Madison County/London City Health District

Mason, Peggy Mental Health Services for Madison County

Padrut, Diana Mental Health Services for Madison County

Payne, Kyli London City Schools

Roberts, Roger Madison County Emergency Management Agency

Runnels, Roselin (Chair) Mental Health Recovery Board

Smoking Cessation

Ben, Tom London City Schools

Braithwaite, Roberta Madison County Sheriff’s Department/Dare Program

Ferguson, Melissa Madison County/London City Health District/West Jefferson Schools

Lee, Maria Madison Health

Michaelson, Jennifer (Chair) Madison County/London City Health District

Neff, Cindy Madison County/London City Health District/Madison Plains Schools

Roddy, Ruth Madison Health


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