HNC 2030 Scorecard: Stokes County 2021-2024
Stokes County Health Department has a mission, “To promote health and safe living, prevent disease, care for the sick, protect the environment and provide essential services to meet community needs.” “Stokes County does not discriminate on the basis of race, color, national origin, sex, religion, age or disability regarding employment or the provision of services.” During the Stokes County Community Health Assessment process, the community confirmed two health priorities. In collaboration with NC DHHS and other community partners, Stokes County will stive to work together to improve overall health within its community.
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The 2022 Stokes County Community Health Assessment priorities are:
- Mental Health /Substance Use
- Chronic Illness
- Healthy Eating/Exercise
Below is a Community Health Improvement Plan (Chip) Scorecard created to meet Stokes County Community Health Improvement Plan requirements.
A key to navigating the scorecard:
The following resources were used to complete this scorecard:
Executive Summary
Executive Summary
The executive summary can be found on pp. 6-7 of the Stokes County Health Assessment Report.
Priorities
CHA Priorities
The 2021 Stokes County Community Health Assessment priorities are as follows:
- Mental Health/Substance Use
- Chronic Illness including health behaviors related to eating exercise and tobacco.
Why Is This Important?
The individuals with mental health issues cycle through county services: hospital emergency departments and, social services. Even if there is access to care, there are cultural stigmas to mental illness that are particularly acute in rural areas and may keep people from seeking care. In a small community where everyone knows everyone, many do not want their car seen in the parking lot of a behavioral health specialist. Despite all of the obstacles, a movement toward changing the balance of access and care in rural regions is showing signs of life.
We have found that those individuals with mental health problems that do not seek help or treatment will often become involved in the aforementioned substance abuse problem in our county. These individuals may turn to prescription drugs or illegal drugs to help the mental conditions that they have (self-medicate) instead of seeking help with a professional. There is a lack of medical providers for Stokes County. The area north of the mountain range is considered medically underserved. With partnerships within the county we hope to improve access to mental health services. Also, we are now working with Vaya Health to increase mental health access for everyone. If we are able to increase access, then more individuals will receive counseling and medication for conditions they have. At this time, we have increased suicide rates which are more than likely due to lack of mental health help when needed.
Why Is This Important?
An average of nine North Carolinians died each day from a drug overdose in 2020, a 40% increase from the previous year. This stark increase during 2020 aligns with the increases experienced nationwide with the nation exceeding 100,000 deaths. In North Carolina, the number of drug overdose deaths — from illicit substances and/or medications — increased by nearly 1,000 deaths, from 2,352 in 2019 to 3,304 in 2020. There were also nearly 15,000 emergency department visits related to drug overdoses in 2020. Provisional surveillance data suggest these increases continued through 2021. Both overdose deaths and the increases disproportionally affect historically marginalized populations.
What We Do
Stokes County’s Department of Social Services Liaison aims to help people experiencing mental and substance use or drug addiction problems. They provide support for people trying to overcome these issues. They work with outpatient clinics, the Stokes County Health Department, local hospitals, mental health clinics or private practices. They will provide resources to the client, such as support groups or programs or refer out to other professionals. They not only work closely with the client building rapport but also families, couples and other individuals that might have been affected.
Who We Serve
Eligibility is based on need, not income. Can help individuals find appropriate social services related to substance abuse.
- Youth/Teens
- Adults
- Clients with substance use disorders.
How We Impact
Providing quality services to promote treatment and recovery for individuals with substance use disorders. "Substance Use Disorder (SUD) services help to prevent misuse of alcohol and other drugs and to help people with substance use disorders in obtaining the appropriate services and supports they need to live a life in recovery. This includes ongoing treatment, as well as a network of services and supports that are person-centered and built on the strengths and resiliencies of individuals, families, and community to achieve improved health, wellness, and quality of life. Access to quality treatment is critical, but so is having good relationships with family or friends, having a job, having a place to live and being around people in recovery." NCDHHS
Progress in 2022-2023
What We Do
The Community Paramedic Program in Stokes County started in 2019 in response to covid.
Funding initially came from Opioid Settlement Funds. The CPP operates out of the Emergency Management system.
The Community Paramedic functions alone and as a member of a healthcare team providing assessment and care to patients with chronic medical, behavioral problems and substance abuse. Identifies patient’s needs and assists in connecting patients with available community and medical resources. As a Community Paramedic must attend to the physical and emotional needs and wellbeing of the patient and when appropriate, the family and significant others. They are a emerging healthcare profession which helps improve rural healthcare. Community Paramedics work to expand roles outside of the ambulance. Community Paramedics of Stokes County work closely with local fire departments, home health agencies, social services, and other officials to ensure patient safety.
Who We Serve
Connecting the citizens of Stokes County to the underutilized resources to underserved populations regarding substance abuse/overdoses. It exists for the sole purpose of serving the needs of a particular community.
How We Impact
The Community Paramedic Program closes the gap by expanding the role of EMS personnel. Bridging the gap between substance use, mental health, and chronic health conditions. We can offer treatment plans to assist through withdrawal symptoms if requirements are met until further assistance is available. We can connect with longer term recovery options.
- Home Safety Assessments
- Care Coordination
- Substance Abuse Resource Navigation
- Mental Health Resource Navigation
- Home Health Coordination
- Transportation assistance to medical appointments
- Physical, Mental and Functional Assessments
- Medication Reconciliation
- Intensive Case Management
- Public Education
- Opioid Response Team
- Offer at home Narcan and provide education along with signs and symptoms of overdose.
Progress in 2022-2023
Stokes County Health Department's Medication Assisted Therapy (MAT) program has been successful in fall of 2023. We were awarded grants to continue to support our clients with their treatment and recovery goals. We continue to see an increase in patients resulting in our largest caseload since the establishment of the program.
What We Do
The goal of our program is to transition clients with current opioid dependency to daily suboxone therapy through a managed care program. Essentially, they stop using opioids in an unsafe and uncontrolled manner (increasing the risk of overdose) and utilize buprenorphine to help stabilize their cravings and allow them to function without the control of the opioid cravings. This is a safe, effective, and controlled method of helping patients who are ready to stop opioid use.
Who We Serve
For people who are currently dependent on either alcohol or drugs such as opioids, there is one treatment available that is particularly effective to help them quit. Medication-Assisted Treatment, also called MAT, helps clients by combining medications and behavioral therapy to heal substance use disorders.
- Adults
- Children and Family
- Veterans or Active Duty
How We Impact
Our medication-assisted treatment program in Stokes, NC, has a “whole-body wellness” approach to treating substance use disorders. With medication-assisted treatment, you can overcome your use disorder, as well as heal any physical, emotional, or mental damage it has caused.
Why Is This Important?
Smoking kills more people than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined — and thousands more die from other tobacco-related causes such as involuntary exposure to secondhand smoke, fires caused by smoking (more than 1,000 deaths/year nationwide) and smokeless tobacco use.
What We Do
"Quitline NC provides free cessation services to any North Carolina resident who needs help quitting commercial tobacco use, which includes all tobacco products offered for sale, not tobacco used for sacred and traditional ceremonies by many American Indian tribes and communities. Quit Coaching is available in different forms, which can be used separately or together, to help any tobacco user give up tobacco.” NCDDHS
Who We Serve
To any North Carolina resident who needs help quitting commercial tobacco use, which includes all tobacco products offered for sale.
How We Impact
"Quitline’s are effective, evidence-based treatments for smoking cessation. The evidence base for tobacco cessation Quitline’s was established through numerous clinical trials and meta-analyses." CDC
Progress in 2022-2023
Stokes County Health Department has started "Quitline" program in 2023 with 10 clients at present and will start keeping total number of referrals.
Progress on CHIPs
All Stokes County priorities are addressed in the Community Health Improvement Plan (CHIP). Click on the links below for Progress Made in 2022-2023.
For the priority area Mental Health see Progress in 2022-2023 note tabs for each program below.
For the priority area Substance Use see Progress in 2022-2023 note tabs for each program below.
- Medication Assisted Therapy (MAT)
- Community Paramedic Program
- Mental Health & Substance Abuse Liaison/Department of Social Services
For the priority area Chronic Disease see Progress in 2022-2023 note tabs for each program below.
- New QuitlineNC
Morbidity and Mortality Changes Since Last CHA
Aside from drug overdose and Covid-19, there are no major changes in morbidity and mortality since the last CHA.
Emerging Issues Since Last CHA
These are the new or emerging issues in our community in 2022 that were not identified as priorities in our CHA.
- Homelessness numbers continue to rise.
- Increase in food needs for seniors related to inflation.
- Economic inflation
- Insurance-higher rates of coverage therefore increase population without
- Transportation
- Increase in Vaping, involving school aged population.
- Affordable Childcare
- Access to Care
- Covid/Flu/RSV
New/Paused/Discontinued Initiatives Since Last CHA
The following are new initiatives or changes in our community in 2022:
- Stokes County Health Department's Health Educator's and clinical staff organized multiple health fairs and vaccine clinics in remote areas of Stokes County.
- Stokes County Substance Abuse Committee
- Stokes County Health Department hired a new Care Manager for high-risk pregnancy.
Progress on CHIPs
All Stokes County priorities are addressed in the Community Health Improvement Plan (CHIP). Click on the links below for Progress Made in 2022-2023.
For the priority area Mental Health see Progress in 2022-2023 note tabs for each program below.
For the priority area Substance Use see Progress in 2022-2023 note tabs for each program below.
- Medication Assisted Therapy (MAT)
- Community Paramedic Program
- Mental Health & Substance Abuse Liaison/Department of Social Services
For the priority area Chronic Disease see Progress in 2022-2023 note tabs for each program below.
- New QuitlineNC
Morbidity and Mortality Changes Since Last CHA
Awaiting for new statistics/data.
Emerging Issues Since Last CHA
These are the new or emerging issues in our community in 2023 that were not identified as priorities in our CHA.
- Lack of Affordable Childcare continues to be an issue.
- Decrease in Drug overdose deaths in 2023.
- Community Health Worker
- Medicaid Transformation
- Increase in seasonal respiratory illness-Covid, Flu, RSV
- New Advisory Board
- Grant Award
- RSV/FLU/STREP seeing increase in outbreaks.
- Covid-19 continues.
- Lack of affordable housing due to inflation
- Economic Inequality/ income gaps
New/Paused/Discontinued Initiatives Since Last CHA
The following are new initiatives in our community in 2023:
- Stokes County Health Department hired a new nurse on staff. Obtained Certificate for Community Health Worker; to work as frontline public health worker for our patients in the community.
- Medication Assistance Therapy Program initiated.
- YMCA partnered with Stokes County Women, Infant and Children's (WIC) Program put on pause due to switch over to electronic benefits. Currently vendors are using vouchers and refuse to switch to electronic.
- Stokes County Health Department hired a new Family Planning Clinic Nurse.
- Stokes County Health Department started an annual, "Back to School Health Fair" to promote health screenings, back to school vaccinations, free haircuts to all children, free backpacks/supplies, free diapers, and feminine hygiene products.
- Stokes County Health Department initiated a spring and fall Diaper Distribution at the two WIC locations.
- Stokes County Medicaid Addiction Treatment Center, "October Road" opened fall 2023.
- Stokes County Jail partnered with Stokes County Health Department Medication-Assisted Treatment Program (MAT)
- Stokes County Emergency Medical Services- (Community Paramedics) partnered with Community Health Worker at Stokes County Health Department for referrals to MAT Program
- Stokes County Department of Social Services and Health Department Employees attained Mental Health First Aid (MHFA)
- Positive Parenting Program (Triple P) has been discontinued at this time.
- Regal Group INC. started a 60+ Senior Food Bank
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