CHNA Final Report

Joy Buck, PhD, RN

Introduction
Community health assessment is an important component of health planning. Every three years, not-for-profit
health care facilities are required to conduct assessments of the communities with the purpose of identifying
significant community health needs, prioritizing health needs, and linking persons with unmet health needs to
community resources.1 In July 2013, the WVU Medicine/University Healthcare (UHC) Board of Directors
(Board) approved the UHC Community Health Needs Assessment (CHNA) and specific health priorities to be
addressed. The CHNA was augmented by broad community input about unmet needs and priorities in the region
and it served as the basis for strategic thinking and planning for each UHC Eastern Panhandle hospital.
The CHNA identified the following areas for community outreach and planning: (1) collaboration with public
health and community-based initiatives to address emergent regional health trends; (2) chronic illness selfmanagement, particularly in community-based diabetes, heart failure, and COPD care; (3) early detection and
timely intervention in cancer targeting breast and lung cancer; and, (4) access to and the quality of behavioral
health services.
The Board further approved the creation of CHNA Implementation Teams (IT) to be chaired by clinical
champions. Three teams in the areas of chronic disease, cancer, and behavioral health were created and cochaired by clinical champions from each hospital. In addition to the champions, IT included representatives from
UHC and key stakeholders from the community. Their charge was to further refine priorities, identify root
causes, develop and/or enhance existing collaborative initiatives to improve access to high value healthcare based
on the priorities and community assets identified by the CHNA. A liaison from UHC leadership was appointed to
each IT. The overall process was guided by a CHNA Steering Committee comprised of champions, team liaisons,
and Joy Buck, PhD, RN, who served as a consultant to the process.

Implementation Team Priorities

While the Berkeley and Jefferson County Medical Centers worked collaboratively, priorities for each hospital
differed slightly. These differences reflect the unique attributes of the hospitals, services each hospital provides,
and the communities they serve. The CHNA identified initiatives that were underway through UHC, JMC, and
BMC, Berkeley and Jefferson County Health Departments, the Health and Human Services Collaborative
(HHSC) and Family Resource Network (FRN), United Way of the Eastern Panhandle, DHHR, and WVU. The
list of regional assets and initiatives included in the CHNA report is extensive. The CHNA found gaps in
communication among the initiatives and interface with UHC hospitals.
Berkeley County priorities included: (1) improved access to high quality healthcare across the continuum and
behavioral health services; (2) reduced costs associated with health care; (3) initiatives to improve dietary habits
and decrease use of tobacco; and, (4) strategies to reduce illicit drug use.

Internal Revenue Service (No date). New Requirements for 501(c) (3) Hospitals Under the Affordable Care Act. Retrieved
from: http://www.irs.gov/Charities-%26-Non-Profits/Charitable-Organizations/New-Requirements-for501%28c%29%283%29-Hospitals-Under-the-Affordable-Care-Act

1|Page

Hospital-specific priorities for Berkeley Medical Center were: (1) diabetes management in acute and
community-based settings; (2) primary and secondary prevention of cancer, particularly breast and lung cancer;
(3) behavioral health in acute and community-based settings; and (4) continuous monitoring of ACS discharges
particularly related diabetes and behavioral health.
Jefferson County priorities included: (1) improved access to high quality care across the continuum and
behavioral health services; (2) initiatives to improve dietary habits, reduce sedentary behavior/increase activity
levels, and reduce illicit drug use; and, (3) strategies to address binge drinking and alcohol-related vehicle crash
fatalities.
Hospital-specific priorities for Jefferson Medical Center were: (1) hospital-wide and community diabetes
initiatives; (2) behavioral health in acute, emergency room, and community-based settings; (3) collaborations to
improve access to health care among persons with lower and fixed incomes; and, (4) strategies to address
community-wide trends related to population demographic trends, specifically, growth in aging and racial/ethnic
minority populations.
Universal problems to be addressed by the CHNA Implementation Teams (IT) were: (1) high prevalence of
substance abuse and gaps in care for persons with serious mental illness; (2) high incidence of and poor health
outcomes among persons with chronic disease such as diabetes, heart disease, and lung disease; and, (3) rising
rates of lung cancer deaths among women in the region and late stage breast cancer diagnoses. The CHNA
identified a fourth priority area focused on maternal/child health disparities. Because community providers and
other community groups were already addressing the issue, it was determined that the development of an
additional UHC team would be redundant. A listing of the initial CHNA champions and liaisons is provided in
Appendix A.

CHNA Implementation Team Interventions and Impact

Chronic Disease: The overall goal of the Chronic Disease IT was to improve the quality of care across the
continuum. The IT focused on diabetes, heart failure, COPD, and stroke and identified the following issues to
address: (1) need for enhanced UHC/community partnerships and patient/family engagement; (2) provide service
to the community through health education; (3) utilization of Wellness Center resources by UHC staff and
community; (4) partnerships and data sharing plans for program evaluation; (5) alignment with UHC quality and
Centers of Excellence initiatives.
Strategies were developed to address internal (hospital) and external (community) gaps and strengthen bridges to
existing community initiatives. Internal strategies included diabetes management quality initiatives and the
reduction of preventable hospitalizations. External initiatives focused primarily on the development of formalized
structures and processes associated with Chronic Disease Self-Management Program (CDSMP) and Diabetes
Self-Management Program (DSMP) sponsored by the Berkeley County Health Department as part of the West
Virginia Community Transformation grant. It is important to note that the grant was defunded in 2014 without
negatively impacting the sustainability of this effort.
Chronic Disease IT Impact

Diabetes
o Diabetes became a hospital-based metric (P/O)2
o Literacy screening was implemented and served as the basis for tailoring educational interventions (P)
(P) = Process indicator; (O) = Outcome indicator; (P/O) indicates both process and outcome indicator.

2|Page

o
o

BMC hyperglycemic day rates consistently within the range of 450-475 (baseline >600) (O)
Reduced severe inpatient hypoglycemic day rate (O)

Readmissions3
o Automated LACE scoring for readmission risk (P)
o LACE scoring used for high-risk post-DC calls at 7, 14, 21, and 30 days (1/15) (P)
o Post-DC follow up phone call within 48-72 hours; scheduling post-DC follow-up visit within 7 days
of DC (P)
o Overall readmission rate stable (O)
o JMC partnership with UHP and WVU/in-home physician visits for at selected at-risk individuals (P)

Community Partnerships
o UHC representation on HHSC Committees, including Health Committee and Healthy Berkeley (P/O)
o Automatic referral to CDSMP/DSMP in EPIC and associated staff education (P)
6 physician referrals to CDSMP/DSMP (P)
o Healthy Communities Grant to support physical activity/healthy nutrition programs downtown (O)
o Try This WV grant for school running and physical activity programs running programs (O)

CDSMP/DSMP
o 13 classes offered June 2013 Dec 2014 (O)
o 163 registrants; 68% retention rate (O)
o 7 classes scheduled for 2015 (P)
o Evaluation process implemented (P)

Cancer: The Cancer IT focused on primary and secondary prevention of breast and lung cancer. The Cancer
Committee, which includes community stakeholder representatives served as the IT. The IT identified the
following gaps to address: (1) access to/utilization of affordable Mammograms; (2) access to/utilization of
affordable chest CT screening for lung cancer among at risk individuals; and, (3) timely follow-up after positive
screening Mammograms (CMS measure). The following goals were developed:

To increase collaboration, awareness, and utilization of cancer available screening

To support efforts, when possible, to decrease gaps and increase awareness of screening efforts such as
low-cost lung and breast cancer screening services
To increase outreach efforts in support of earlier detection of cancer and access to treatment which
ultimately will impact overall cancer survival rates.

Strategies to realize the goals included hiring outreach workers in Jefferson and Berkeley counties
(10/week/county), offering affordable lung CT screening for at risk individuals, marketing low cost
Mammograms annually in May and October, and working with Mountains of Hope and Bonnies Bus to improve
access to low cost Mammograms. The commitment to community engagement through outreach workers is an
important step to understanding cultural factors that impact cancer screening and outcomes in the region. In
addition, internal processes to assure timely follow-up after positive screening Mammograms were examined and
improved.
Cancer IT Impact

Mammogram follow-up
CMS changing reporting of readmissions to analyze expected/observed ratio.

3|Page

Improved percentage of outpatients who had a follow-up mammogram, ultrasound, or MRI of the
breast within 45 days after a screening mammogram (CMS indicator - a follow-up rate near zero
may indicate missed cancer; a rate higher than 14% may mean there is unnecessary follow up.)
BMC 5.5% (2.8% baseline) (O)
JMC 1.9% (No baseline/reporting not required of CAH) (P/O)
WV 8.8%; National 8.8%
Improved processes for Mammogram follow-up at Berkeley Medical Center (Appendix C)
100% of mammogram reports offered same day of screening (P/O)
100% of persons with positive screening Mammogram received results and referral same day

Outreach to promote early detection and intervention

o Outreach workers hired in Berkeley and Jefferson County (P)
1,200 breast cancer screening fliers in Berkeley and Jefferson County Schools (O)
Regular outreach meetings to discuss strategies (P)
Intake forms incorporate questions to assess effectiveness of outreach activities (P)
o Access to affordable Mammograms
Low cost Mammograms in May and October offered at both hospitals (P)
> 200 promo Mammogram participants 2014-2015 (O)
Supported community mobile Mammogram - Bonnies Bus (P)
71 participants/over 50% did not have insurance (O)
Over 50% of participants would not have otherwise had screening (O)
o Access to affordable chest CT for high risk individuals
90 persons screened at a reduced program rate (O)
50% had lung nodules; 37% of those persons had nodules greater than 4 mm

Behavioral Health IT: The Behavioral Health IT focused on both internal and external capacity to address the
following identified gaps in regional behavioral health: (1) inadequate access to quality behavioral health and
substance abuse services; (2) increased substance abuse/ behavioral health-related emergency room visits; (3)
prevalence and perceived burden of regional behavioral health and substance abuse; and, (4) limited
understanding of mental illness and substance abuse issues and treatment among lay and professional community.
Strategies to address internal and external capacity included the following:

Educate University Healthcare staff and providers about assessment and treatment of mental illness and
substance abuse prevention/recovery, including crisis intervention, referral to area resources, and
physician education on appropriate prescription of opioids
Increase distribution of behavioral health/substance abuse specific information and resources to staff,
patients and families
Enhance employee support services for staff well-being and morale
Improve continuity of care through better collaboration with community-based behavioral
health/substance abuse providers and services; including improvement with already established BH work
group and hospital liaison to East Ridge
Increase utilization of education and community treatment options leading to increased patient stability
while decreasing utilization of emergency room visits as primary point of care
Establish a connection with National Alliance for Mental Illness (NAMI)

A variety of internal activities were developed and offered to improve employee support services. These
strategies included stress management workshops on units, quarterly self-care workshops, and creation and
promotion of an educational library. Additional strategies included building stronger relationships with
community providers and support networks. Specifically, one part-time outreach position was created at BMC to
increase interface with community groups and leaders. Two full-time LPCs were hired at JMC to develop and
4|Page

submit a CON for an Intensive Outpatient Program (IOP) in Jefferson County. The JMC LPCs were shared with
UHP to provide behavioral health services at Harpers Ferry Family Medicine. Increased capacity for BMC and
JMC outreach resulted in UHC representation on HHSC Behavioral Health Workgroup (both Berkeley and
Jefferson Counties) and the Behavioral Health Policy Sub-Committee that produced a white paper on behavioral
health in the region and sponsored the Behavioral Health Policy Summit in December 2014. Moreover, the BMC
Behavioral Health Program received MAPP mini-grant funding to support the first Mental Health First Aid
training in the state.
Finally, one of the major problems identified by the CHNA and the Behavioral Health IT was the lack of
coordination among behavioral health providers and initiatives in the region. UHC created a Behavioral Health
Steering Committee comprised of key leaders from all Eastern Panhandle sectors to begin the discussion on a
coordinated approach to behavioral health in the region. The group (Appendix B) was convened in fall 2014. The
group met twice and there is a third meeting planned for fall 2015 to discuss the CHNA final report and make
recommendations about the role of the Steering Committee in light of the emergent community initiatives.
Behavioral Health IT Impact

Internal Initiatives
o Ongoing staff education and new program development (P)
BMC: Care for the caregiver, PHQ-9 screening, advanced Code Gray training, SBIRT
screening, and substance use/abuse education. (P/O)
JMC: Workplace bullying and exhaustion, Suicide and prevention, the effects of
trauma/PTSD, Mental Health Awareness month activities including MindStorm: A Virtual
Hallucination (P/O)
o Creation of a website with UHC and community behavioral health resources and screening tools (P)
o Inclusion of evidence-based suicide screening instrument into EPIC (P)
o Creation of a local National Alliance for Mental Illness (NAMI) peer support and advocacy group
(P/O)
o Incorporation of PHQ-9 screening into EPIC for all hospital admissions (put on hold) with physician
referral mechanisms (P)

External Initiatives
o Outpatient programs addressing community needs (P)
o Better understanding of community perspectives about gaps in services (O)
o Enhanced articulation with community-based behavioral health providers and services (P/O)
o Jefferson County CON for Intensive Outpatient Program (IOP) approved (P/O)
o Collaboration with Behavioral Health Workgroup on BH Policy Summit (12/14) (O)
o Representation on HHSC Behavioral Health Workgroup and Legislative Sub-Committee (O)
Development of Behavioral Health Resource Guide maintained by FRN (P/O)
Development of behavioral health white paper to inform workforce development and
program planning (P/O)
o External MAPP funding to support Mental Health First Aid training (O)
o BMC outreach worker certified as Mental Health First Aid trainer in 2014 (O)
3 trainings offered with over 70 participants (O)
Overwhelmingly positive evaluations of trainer and content
Additional trainer trained in 2015 (P/O)
Collaboration with Berkeley County Schools Project Impact to provide additional MHFA
training to Martinsburg Police with additional trainings in planning stages (P/O)

Strengths and Limitations

5|Page

One of the major strengths of the CHNA/Implementation Plan was the level of commitment of the champions, the
teams they worked with, and UHC investment in the process. At the beginning of the project, none of the
champions or teams had dedicated time to commit to the project. The degree of time and effort that went into
developing and implementing the strategies cannot be understated. For example, creating an IOP and submitting
a successful CON application is a monumental task that was accomplished in relatively short period of time.
Similarly, incorporating health screening, such as the PHQ-9, literacy screening, and automatic referrals to
community programs into EPIC takes time, energy, and responsiveness of individuals and systems to
accommodate requisite changes. All of the persons involved with the CHNA Implementation Plan and associated
projects should be commended for their diligence and hard work.
Another strength of the CHNA/Implementation Plan was the level of community engagement in the process. By
engaging the community in the development of strategies to improve community health, the credibility and
sustainability of health improvement efforts and the image of University Healthcare and its vital role in the health
of the community was enhanced. Perhaps more importantly, the investment in outreach workers and development
of new health programs that extended out into the community, created new and sustainable partnerships that will
significantly improve access to high value healthcare in the region into the future.
An incidental outcome of the CHNA was improved collaboration between the two hospitals. By working together
on the CHNA projects, champions from the different hospitals began collaborating on different projects. They
also consulted with each other about various problems or concerns and seized opportunities to share information
and data to the benefit of both hospitals. This was also true of the champions from the different priority areas.
When discussing their thoughts on priorities for the next CHNA cycle, the CHNA Steering Committee
unanimously agreed that cross-cutting interventions that address the links between chronic illness, behavioral
health issues, and cancer are needed.
In summary, the CHNA provided data to support a shift organizational culture and responsiveness to emergent
and long-standing health problems in the region. It prompted (1) changes to internal processes that improved the
quality of inpatient care; (2) collaboration with community groups to improve the interface between acute and
community-based care for persons with complex health challenges; and, (3) communication, coordination, and
collaboration among the champions and between UHC hospitals.
While there were many positive outcomes associated with the CHNA, there are were limitations as well. One
limitation was the emergent design of the CHNA Implementation Plan. This was primarily due to the limited
guidance provided to hospitals about IRS expectations for the assessment, implementation plan, and its evaluation
until early in 2015. Another factor necessitating flexibility of the plans was system and organizational changes
and conflation of CHNA strategies and larger hospital initiatives. For example, after initiation of the Diabetes
initiative, Diabetes became a Quality Blue initiative. This Quality Blue initiative positively impacted the Chronic
Disease ITs effectiveness but also blurred the lines between the strategies that were part of the CHNA and those
strategies that were linked to the Quality Blue initiative. While the process indicators for each are clear, the
outcomes associated with these linked initiatives are not easily discerned.
System constraints also confounded some of the initiatives as evidenced by the Chronic Disease IT readmission
strategy. Larger system factors impacting the strategy included CMS requirements and associated financial
incentives/disincentives related to hospital readmissions that impacted BMC.4 The IT strategies were
incorporated into larger initiatives to address preventable readmissions, including processes to incorporate LACE
criteria into assessments and interventions. Conversely, the initial plan to develop a discharge clinic for at-risk

JMC is as critical access hospital and not subject to the same requirements.

6|Page

persons without a medical home and home health strategies were postponed due to diversion of staff time to
higher priorities, system constraints, and lack of personnel to effect the requisite changes.
In summary, the CHNA limitations are emblematic of the nature of the healthcare system as a whole, UHC
responses to the challenges and opportunities inherent in todays healthcare environment, and the breadth and
depth of the initial strategies and their practical application. Overall, the CHNA implementation plan strengths
far outweigh its limitations and UHC is well positioned for the second CHNA cycle.

Implications and recommendations

Early in 2015, the final IRS CHNA rules were released and reviewed. The first cycle CHNA process and
evaluation was compared to the final rules and preliminary plans for cycle 2 were developed accordingly. The
2015 IRS regulations stipulate the following changes in required documentation: 5

Cycle 2 may build off prior CHNA but must solicit and consider input from persons representing the
broad interests of the community anew with each CHNA.*6
o If input from persons representing the community of interest cannot be obtained, the CHNA must
describe the efforts used to solicit such input**
Definition of needs expanded to include multiple determinants of health *
Evaluation of the impact of cycle 1 not included in the final report may be incorporated into cycle 2 */**
Outcomes may include both qualitative and quantitative measures**
o IRS is not prescriptive about how to measure but there must be a rationale for approach taken*/**
Definition of community must:
o Encompass large enough area to allow population-wide interventions and measurable results**
o Include a targeted focus to address disparities among subpopulations*/**
Strategies must:
o Be directly linked to community health/benefit activities*
o Be targeted for impact (outcomes)*/**
o Build strategic partnerships and consumer engagement*
o Enhance care delivery system*/**
o Provide insight for population health management, programs, and strategies*/**
o Improve access to care*

Once the final report is approved by the UHC Board, the CHNA Steering Committee will reconvene to design the
next CHNA cycle assessment and timelines. Since the MAPP project ended in 2014, the Steering Committee will
consider the possibilities of collaborating with local health departments and other community groups in the
CHNA design, assessment tool (i.e. community survey) development, and focused interventions or strategies with
appropriate population health outcome measures. This process will take place between November 2015 and
January 2016 and once approved by the UHC Board, the next cycle will commence early in 2016.7

Internal Revenue Service (No date). New Requirements for 501(c) (3) Hospitals Under the Affordable Care Act. Retrieved
from: http://www.irs.gov/Charities-%26-Non-Profits/Charitable-Organizations/New-Requirements-for501%28c%29%283%29-Hospitals-Under-the-Affordable-Care-Act
6
Strengths of the first CHNA cycle are denoted by *. Changes to incorporate into cycle 2 are denoted by **. */** denotes a
strength that can be enhanced or more clearly defined in cycle 2.

7|Page

Appendix A: CHNA Implementation Teams

Team
Behavioral Health
Mental Illness, Substance Abuse, and
Recovery

Chronic Disease/Illness
Diabetes, COPD, Stroke, and
CHF
Cancer
Breast cancer and Lung cancer
Maternal/Child Health Disparities
(Issue being addressed by community
group with UHC representation)

Name
Arlene Fernandez-Anderson, BSN
Gisele Perry, LPC (2014/15)
Katherin Weiss, MA, BSN
(2014/15)
Valerie Borman, BSW
Dana DeJarnett, MS
Barb Sherman, MSN, FNP
Pam Gesford, MSN
Jessica Buck, BA
Teresa McCabe
Terry Reiser, MSN (2013)
Yvonne Katz
Chris Knight
Sandy Martin
Melanie Riley

Hospital
JMC
JMC
BMC
BMC

Role
Liaison
Champion
Champion
Champion

BMC
BMC
BMC
JMC
UHC
BMC
Both
UHC
JMC
BMC

Liaison
Champion
Champion
Champion
Liaison
Champion
Champion
Liaison
Champion
Champion

Appendix B: UHC Behavioral Health Steering Committee

Andrew Garcia
Angela Porturica
Audrey Morris
Bill Clark
Dave Fant
Debbie Maiorano
Dr. Joy Buck
Giselle Perry
Jim Barnhart
Joy Lewis
Kevin Knowles
Lt. Dave Colbert
Patsy Noland
Penny Porter
Pete Dougherty
Pete Mulford
Rick Stoltz
Ronda Lehman
Sgt. S. E. Davis
Stacy Dugan
Teresa McCabe
TFC J.C. McDonald
Thomas S. Kimm
Tiffany Lawrence
Tina Burns

8|Page

City of Martinsburg Police and Private Citizen

Berkeley Medical Center
Starting Points FRC
Region 9 P & D
Shenandoah Valley Medical System, Inc.
Self Employed, LPC
WVU School of Nursing/Eastern Division
Jefferson Medical Center/UHP
Berkeley County Council
Governors Office
City of Martinsburg Roach Oil
Jefferson County Sheriffs Dept.
Jefferson County Commission
United Way of the Eastern Panhandle
Jefferson County Sheriff
United Way of the Eastern Panhandle
East Ridge Health System, Inc.
United Way/Teen Court Jefferson County
WV State Police
Morgan Co. Chamber of Commerce & War Memorial Hospital
University Healthcare
WV State Police
Recovery WV
United Way of the Eastern Panhandle/WV Legislature
Shenandoah Community Health

Appendix C: Berkeley Medical Center Mammogram Screening Follow-up January through March, 2015
BMC Mammogram Screening Same Day Follow-up January - March, 2015
700
600
500
400
300
200
100
0

Screened

Waited

Positive Screen

Positive Waited

Jan-15

528

243

66

66

Feb-15

529

255

51

51

Mar-15

602

281

51

51

Jan-15

9|Page

Feb-15

Mar-15