University Healthcare
Community Health Needs Assessment
&
Strategy Implementation Plan
Joy Buck, PhD, APRN
Professor, WVU School of Nursing
Robert C. Byrd Health Sciences Center, Eastern Division
Approved by the WVU Medicine/University Healthcare Board of Directors April 3, 2017
Suggested Citation: Buck, J. (2017). 2017 University Healthcare Community Health Needs
Assessment and Strategy Implementation Plan. Available at http://wvumedicine.org/university-
healthcare.org/berkeley.
, Contents
2016 Community Health Needs Assessment .....................................................................................................5
Introduction and Background .........................................................................................................................5
Report Methods and Organization .................................................................................................................6
CHNA Design ...................................................................................................................................................7
World Health Organization Determinants of Health ......................................................................................7
Key Indicators and Data Sources ....................................................................................................................8
Centers for Medicare and Medicaid Services (CMS) Hospital Compare ........................................................9
Data Analysis.............................................................................................................................................10
Priorities, Recommendations and Implementation Plan .............................................................................10
Community Health Needs Assessment Cycle 1 ................................................................................................12
Activities since CHNA Cycle I ........................................................................................................................12
Chronic Disease Implementation Team ...................................................................................................13
Impact .......................................................................................................................................................13
Cancer Implementation Team ..................................................................................................................14
Cancer Implementation Team Impact ......................................................................................................14
Behavioral Health Implementation Team ................................................................................................14
Behavioral Health Implementation Team Impact ....................................................................................15
Changes Since CHNA I ...................................................................................................................................15
Behavioral Health .....................................................................................................................................15
Cancer Care...............................................................................................................................................16
CHNA Cycle II ....................................................................................................................................................18
Executive Summary ......................................................................................................................................18
Priorities .......................................................................................................................................................21
Community Perspectives on Critical Health and Safety Priorities and Key Drivers..................................22
CHNA Cycle II Priorities .............................................................................................................................24
Strategy Implementation Plan ..................................................................................................................28
CHNA Cycle II Implementation Champions and Teams ............................................................................28
Key Findings ......................................................................................................................................................31
Population Demographics .......................................................................................................................31
2016 County Health Rankings ..................................................................................................................31
Page | 1
, Population with Limited English Proficiency (LEP) and Living in Limited English Households .................31
CDC Community Health Status Indicators ................................................................................................32
Social and Economic Determinants of Health ..............................................................................................32
Income ......................................................................................................................................................32
Cost of Healthcare ....................................................................................................................................33
Health Insurance ......................................................................................................................................33
Education .................................................................................................................................................33
Housing Cost Burden/Housing .................................................................................................................34
Food Security ...........................................................................................................................................34
Behavioral Health .....................................................................................................................................34
Maternal/Infant Health ...........................................................................................................................35
Families with Children .............................................................................................................................35
Hospital Level Data ......................................................................................................................................36
Berkeley Medical Center ..........................................................................................................................36
Jefferson Medical Center..........................................................................................................................36
BMC Ambulatory Care Sensitive (ACS) Inpatient Admissions (2013-2015)..............................................36
JMC Ambulatory Care Sensitive (ACS) Inpatient Admissions (2013-2015)...............................................37
Berkeley Medical Center Cancer Registry (2013-2015) ...........................................................................37
Jefferson Medical Center Cancer Registry (2013-2015) ...........................................................................37
Cancer Mortality ......................................................................................................................................38
Community Health Needs Assessment Cycle II ................................................................................................39
Community Themes and Strengths and Health System Assessment Survey ...............................................39
Demographics ...........................................................................................................................................39
Selected Quality of Life Questions............................................................................................................41
Health System Assessment .......................................................................................................................42
Access Behavior and Barriers ...................................................................................................................43
7-Item Assessment of Chronic Illness Care Subscale................................................................................45
Personal Health Status .............................................................................................................................45
Responses to the question “ .....................................................................................................................46
Community Perspectives on Critical Health and Safety Issues and Priorities ..........................................47
Factors Contributing to Critical Health and Safety Issues ........................................................................47
Hospital Level Data .......................................................................................................................................48
Centers for Medicare and Medicaid Services (CMS) Hospital Compare ..................................................48
Page | 2
, CMS Hospital Compare Selected Patient Satisfaction Measures for BMC and JMC ................................48
Diagnosis-Related Groups (DRGs) ............................................................................................................51
Ambulatory Care Sensitive Admissions ....................................................................................................52
Diabetes ....................................................................................................................................................54
Behavioral Health .....................................................................................................................................55
Behavioral Health Crisis Intervention Team .............................................................................................57
Cancer ......................................................................................................................................................58
West Virginia Cancer Burden ....................................................................................................................58
Cancer Mortality .......................................................................................................................................58
BMC and JMC Cancer Registry 2013-2015 ...............................................................................................58
Age and Stage at Time of Cancer Diagnosis .............................................................................................60
Cancer Disparities .....................................................................................................................................62
Cancer and Palliative Care ........................................................................................................................62
HPV-related cancer ...................................................................................................................................64
Maternal, Neonate, and Infant Health .....................................................................................................65
Health System Assessment ...............................................................................................................................68
Community Health Status Assessment.............................................................................................................70
Population Demographics ............................................................................................................................70
Female and Male Population ....................................................................................................................70
Population Under Age 18 and Age 65 and Older .....................................................................................71
Race and Ethnicity ....................................................................................................................................71
Change in Total Population ......................................................................................................................72
Family Households with Children .............................................................................................................73
Family Households with Children by Race Alone, Percent .......................................................................74
Social and Economic Determinants of Health ..............................................................................................74
Median and Per Capita Income ................................................................................................................74
Children Living in Poverty .........................................................................................................................75
Children Eligible for Free or Reduced Price Lunch ...................................................................................75
Income - Inequality ...................................................................................................................................76
Eligibility for SNAP Benefits ......................................................................................................................77
Housing Cost Burden (30%) ......................................................................................................................77
Cost of Healthcare ....................................................................................................................................78
Uninsured Adults and Children.................................................................................................................78
Page | 3
Community Health Needs Assessment
&
Strategy Implementation Plan
Joy Buck, PhD, APRN
Professor, WVU School of Nursing
Robert C. Byrd Health Sciences Center, Eastern Division
Approved by the WVU Medicine/University Healthcare Board of Directors April 3, 2017
Suggested Citation: Buck, J. (2017). 2017 University Healthcare Community Health Needs
Assessment and Strategy Implementation Plan. Available at http://wvumedicine.org/university-
healthcare.org/berkeley.
, Contents
2016 Community Health Needs Assessment .....................................................................................................5
Introduction and Background .........................................................................................................................5
Report Methods and Organization .................................................................................................................6
CHNA Design ...................................................................................................................................................7
World Health Organization Determinants of Health ......................................................................................7
Key Indicators and Data Sources ....................................................................................................................8
Centers for Medicare and Medicaid Services (CMS) Hospital Compare ........................................................9
Data Analysis.............................................................................................................................................10
Priorities, Recommendations and Implementation Plan .............................................................................10
Community Health Needs Assessment Cycle 1 ................................................................................................12
Activities since CHNA Cycle I ........................................................................................................................12
Chronic Disease Implementation Team ...................................................................................................13
Impact .......................................................................................................................................................13
Cancer Implementation Team ..................................................................................................................14
Cancer Implementation Team Impact ......................................................................................................14
Behavioral Health Implementation Team ................................................................................................14
Behavioral Health Implementation Team Impact ....................................................................................15
Changes Since CHNA I ...................................................................................................................................15
Behavioral Health .....................................................................................................................................15
Cancer Care...............................................................................................................................................16
CHNA Cycle II ....................................................................................................................................................18
Executive Summary ......................................................................................................................................18
Priorities .......................................................................................................................................................21
Community Perspectives on Critical Health and Safety Priorities and Key Drivers..................................22
CHNA Cycle II Priorities .............................................................................................................................24
Strategy Implementation Plan ..................................................................................................................28
CHNA Cycle II Implementation Champions and Teams ............................................................................28
Key Findings ......................................................................................................................................................31
Population Demographics .......................................................................................................................31
2016 County Health Rankings ..................................................................................................................31
Page | 1
, Population with Limited English Proficiency (LEP) and Living in Limited English Households .................31
CDC Community Health Status Indicators ................................................................................................32
Social and Economic Determinants of Health ..............................................................................................32
Income ......................................................................................................................................................32
Cost of Healthcare ....................................................................................................................................33
Health Insurance ......................................................................................................................................33
Education .................................................................................................................................................33
Housing Cost Burden/Housing .................................................................................................................34
Food Security ...........................................................................................................................................34
Behavioral Health .....................................................................................................................................34
Maternal/Infant Health ...........................................................................................................................35
Families with Children .............................................................................................................................35
Hospital Level Data ......................................................................................................................................36
Berkeley Medical Center ..........................................................................................................................36
Jefferson Medical Center..........................................................................................................................36
BMC Ambulatory Care Sensitive (ACS) Inpatient Admissions (2013-2015)..............................................36
JMC Ambulatory Care Sensitive (ACS) Inpatient Admissions (2013-2015)...............................................37
Berkeley Medical Center Cancer Registry (2013-2015) ...........................................................................37
Jefferson Medical Center Cancer Registry (2013-2015) ...........................................................................37
Cancer Mortality ......................................................................................................................................38
Community Health Needs Assessment Cycle II ................................................................................................39
Community Themes and Strengths and Health System Assessment Survey ...............................................39
Demographics ...........................................................................................................................................39
Selected Quality of Life Questions............................................................................................................41
Health System Assessment .......................................................................................................................42
Access Behavior and Barriers ...................................................................................................................43
7-Item Assessment of Chronic Illness Care Subscale................................................................................45
Personal Health Status .............................................................................................................................45
Responses to the question “ .....................................................................................................................46
Community Perspectives on Critical Health and Safety Issues and Priorities ..........................................47
Factors Contributing to Critical Health and Safety Issues ........................................................................47
Hospital Level Data .......................................................................................................................................48
Centers for Medicare and Medicaid Services (CMS) Hospital Compare ..................................................48
Page | 2
, CMS Hospital Compare Selected Patient Satisfaction Measures for BMC and JMC ................................48
Diagnosis-Related Groups (DRGs) ............................................................................................................51
Ambulatory Care Sensitive Admissions ....................................................................................................52
Diabetes ....................................................................................................................................................54
Behavioral Health .....................................................................................................................................55
Behavioral Health Crisis Intervention Team .............................................................................................57
Cancer ......................................................................................................................................................58
West Virginia Cancer Burden ....................................................................................................................58
Cancer Mortality .......................................................................................................................................58
BMC and JMC Cancer Registry 2013-2015 ...............................................................................................58
Age and Stage at Time of Cancer Diagnosis .............................................................................................60
Cancer Disparities .....................................................................................................................................62
Cancer and Palliative Care ........................................................................................................................62
HPV-related cancer ...................................................................................................................................64
Maternal, Neonate, and Infant Health .....................................................................................................65
Health System Assessment ...............................................................................................................................68
Community Health Status Assessment.............................................................................................................70
Population Demographics ............................................................................................................................70
Female and Male Population ....................................................................................................................70
Population Under Age 18 and Age 65 and Older .....................................................................................71
Race and Ethnicity ....................................................................................................................................71
Change in Total Population ......................................................................................................................72
Family Households with Children .............................................................................................................73
Family Households with Children by Race Alone, Percent .......................................................................74
Social and Economic Determinants of Health ..............................................................................................74
Median and Per Capita Income ................................................................................................................74
Children Living in Poverty .........................................................................................................................75
Children Eligible for Free or Reduced Price Lunch ...................................................................................75
Income - Inequality ...................................................................................................................................76
Eligibility for SNAP Benefits ......................................................................................................................77
Housing Cost Burden (30%) ......................................................................................................................77
Cost of Healthcare ....................................................................................................................................78
Uninsured Adults and Children.................................................................................................................78
Page | 3
