HNC 2030 Scorecard: Pitt County
Executive Summary
Pitt County Health Department (PCHD) and Vidant Medical Center (VMC) are pleased to present the 2021- 2022 Community Health Needs Assessment (CHNA), which provides an overview of the methods and processes used to identify and prioritize significant health priorities and indicators in Pitt County. This CHNA is also part of a regional collaborative with Health ENC that is comprised of health departments and hospitals in eastern North Carolina. Health ENC uses a shared approach for primary and secondary data collection to produce a comprehensive Regional Community Health Needs Assessment, in addition to individual county assessments. As part of the Affordable Care Act, not for profit and government hospitals are required to conduct CHNAs every three years. Similarly, local health departments in North Carolina are required by the Division of Public Health (DPH) in the NC Department of Health and Human Services (NC DHHS) to conduct community health assessments once every four years. PCHD has elected to conduct an assessment every three years, in collaboration with VMC. Since 1997, VMC (formerly Pitt County Memorial Hospital), the PCHD, and Pitt Partners for Health (PPH) have conducted joint CHNAs and worked together to build a healthier Pitt County. PPH is a grassroots organization consisting of local stakeholders that started in 1995 and serves as the county’s comprehensive health coalition. VMC’s Community Health Programs department serves as the administrative agency for PPH. The data collection portion of this CHNA is composed of primary data (community opinion survey and focus groups) and secondary data, including morbidity and mortality statistics, as well as emergency department and inpatient admissions statistics from VMC. The CHNA data were reported at a virtual PPH meeting in November of 2021 by representatives from the health department and hospital. At a subsequent meeting, a consultant from the North Carolina Division of Public Health provided a presentation on “Healthy NC 2030: A Path toward Health.” This presentation represented work by a State task force, led by the NC Institute of Medicine, that prioritized health equity by selecting indicators related to health disparities within the State. Indicator topics included Social & Economic Factors, Physical Environment, Health Behaviors, Clinical Care, and Health Outcomes. PPH members were given the opportunity to vote for the top three health priorities/indicators to address over the next three years, based upon the needs represented by the data, and availability of adequate support in the PPH coalition and the community. These include: 1) Access to Care/Social Determinants of Health (Individuals living below 200% of the Federal Poverty Level); 2) Healthy lifestyles (Limited access to healthy foods); and 3) Mental / Behavioral Health (Adverse childhood experiences; Individuals living below 200% of the Federal Poverty Level). In February of 2022, the VMC Board of Trustees adopted PPH’s recommended health priorities/indicators to [PITT COUNTY 2021-2022 Community Health Needs Assessment 7 address over the next three years. The CHNA data presentation was also jointly conducted by representatives from the PCHD and VMC in November of 2021 to the Pitt County Board of Health (BOH) during a televised and livestreamed meeting, reaching the broader community. BOH members continued to review the data in greater detail during subsequent meetings. In March of 2022, the BOH selected health priorities/indicators similar to those recommended by PPH, as well as additional indicators to address over the next three years, based upon both secondary data and primary data collected from community members. These include: 1) Chronic Disease Prevention with a focus on Improving access to health foods, Reduction of sugar sweetened beverage consumption, and Increase of Physical Activity; 2) Mental / Behavioral Health; and 3) Infant Mortality Prevention. By September 2022, the Pitt County Health Department will release a Community Health Improvement Plan based upon the health priorities/indicators selected by the BOH. The VMC Board of Trustees will approve an Implementation Strategy that addresses the adopted health priorities/indicators as recommended by PPH.
Priorities
1) Chronic Disease Prevention with a focus on Improving access to health foods, Reduction of sugar sweetened beverage consumption, and Increase of Physical Activity
2) Mental / Behavioral Health
3) Infant Mortality Prevention
Why Is This Important?
According to the Centers for Disease Control and Prevention, "In addition to giving us key information about maternal and infant health, the infant mortality rate is an important marker of the overall health of a society."
Infant Mortality represents the health of a vulnerable age group and can provide context to support interpretion of the years of potential life lost (YPLL) in a county. Infant mortality is also commonly used to examine global health differences, as well as to understand historic racial inequities in the United States.
What We Do
The Women, Infants and Children (WIC) Program is a Special Supplemental Nutrition Program designed to provide food to low-income pregnant, breastfeeding and postpartum women and their infants and children until the age of five. WIC offers a combination of nutrition education, supplemental foods, breastfeeding promotion and support and referrals to health care. The WIC Program has proven effective in preventing and improving nutrition related health problems within its population. PCHD_WIC_June2021.mp4
The purpose of WIC is to improve pregnancy outcomes, increase breastfeeding intiation and duration rates, reduce maternal and early childhood morbidity and mortality, and maximize the growth and development of children through improved nutritional status.
N.C. DHHS: DPH: Nutrition Services Branch: WIC (nutritionnc.com)
Who We Serve
WIC is for:
- Children up to 5 years of age
- Infants
- Pregnant women
- Breastfeeding women who have had a baby in the last 12 months
- Women who have had a baby in the last 6 months
WIC is available to pregnant, breastfeeding and postpartum women, infants and children up to age five. Foster families with qualifying individuals may be eligible to receive WIC benefits. To participate, these persons must:
- Live in North Carolina.
- Have a family income less than 185% of the U.S. Poverty Income Guidelines. A person receiving Medicaid, Work First Families Assistance (TANF), or assistance from the NC Food and Nutrition Services automatically meets the income eligibility requirement.
- Be at nutritional risk. A nutritionist or other health professional makes the nutritional risk assessment at no cost to the participant, usually at the local WIC office.
How We Impact
1. Provide Access to WIC Progam Services for Women
2. Promote Healthy Weights
3. Breastfeeding Promotion and Support
Progress in 2022-2023
Add progress in 2022 and 2023
What We Do
For 20+ years, babies in Pitt County have died before their first birthday at nearly twice the State rate of infant mortality. When looking at this trend, health educators at Pitt County Health Department found that infant death associated with unsafe sleep was and still is an issue in Pitt County. Simply put, caregivers of babies in Pitt County need education on safe sleep. Babies in Pitt County need a safe place to sleep.
Pitt County Health Department (PCHD) partners with a National program called Cribs for Kids to provide cribs and educate caregivers about safe sleep. Learn more at Our Story – Cribs for Kids.
Who We Serve
We serve pregnant women or caregivers of child(ren) under 12 months living in Pitt County and receiving public assistance (i.e., WIC, SNAP - Food and Nutrition Services, Medicaid).
How We Impact
Provide educational classes on infant safe sleep practices to parents and caregivers.
Provide safe sleep items such as: portable cribs including sheet, sleep sacks, pacifiers.
Participate in community educational events to increase awareness of safe sleep practices.
Progress in 2022-2023
Add progress for 2022 & 2023
What We Do
The purpose of NC Baby Love Plus (NC BLP) is to improve birth outcomes and the health of women reproductive age through strengthening the perinatal systems of care, building family resilience, promoting quality services and increasing community capacity to address perinatal disparity.
NC BLP provides case management/care coordination services to referred pregnant participants, if necessary, throughtout the interconception period with their children up to 18 months after birth.
Who We Serve
Childbearing women ages 15-44 who meet the following criteria:
- 80% of women enrolled are African American or American Indian ages 15-44; 20% other racial groups
- Previous short birth interval
- Chronic condition needing education for risk reduction
- Homelessness/unstable housing
- Chronic issues with health care appointment compliance
- Previous poor birth outcome or loss
- STI infection
- History of substance abuse/depression or other mental health diagnosis
- Domestic / intimate partner violence
- No reproductive life plan or family planning method used/ or inconsistent use
- History of abuse/neglect or current CPS involvement
- Parenting skill building
- Financial concerns/lack of resources
- Lack of social support
Fathers of the baby and/or male partners of the women enrolled in the NCBLP are eligible to participate in program services.
How We Impact
Preconception - Provide preconception case management/care coordination services to a minimum of 40 unduplicated women. A Famliy Outreach Worker (FOW) will:
1. Follow up with prospective program participants (within seven days of referral to the NC BLP program) to answer program related questions, initiate enrollment.
2. Ensure that program participants have a medical home through consistent case management.
3. Conduct monthly care coordination contacts by phone or in-person' (in the office, clinic, or community location).
4. Conduct quarterly health education/support group sessions for program participants to provide education regarding the various contraceptive methods and other positive preconception and reproductive health behaviors.
Prenatal (pregnant) - Provide case management/care coordination services to a minimum of 120 unduplicated pregnant women. A Family Care Coordinator (FCC) will:
1. Follow up within 7 days of referral with prospective program participants to answer program related questions, initiate enrollment.
2. Ensure that program participants have a medical home through consistent case management and by ensuring they remain connected to their pregnancy medical home through attending prenatal visits and related referrals.
3. Develop an individualized care plan with each participant. This care plan outlines the steps to be taken to address each family's identified needs.
4. Collaborate with the Family Outreach Worker to hold group prenatal education sessions twice a month. Sessions will include topics such as: basic health during pregnancy, healthy eating; stress management, substance use, labor and birth information, care for an infant, breastfeeding, oral health, understanding perinatal mood disorders, reproductive life planning, postpartum care, including postnatal warning signs, and community support services.
5. Conduct monthly case management/care coordination contacts by phone, virtually, or in-person.
6. Recruit and refer a minimum of 40 fathers/male partners to the NC BLP Dads program, ensuring a "warm handoff'' from the FCC to the Fatherhood Coordinator.
Interconception - Provide case management/care coordination services to a minimum of 40 unduplicated interconception women and a minimum of 40 unduplicated infants.
The Family Care Coordinator will:
1. Ensure that participating women and infants have a medical home through consistent case management and by ensuring participants remain connected to their medical home through attendance at well-woman and well-child visits and related referrals.
2. Develop individual care plan.
3. Conduct monthly case management/care coordination contacts by phone or in person (in the home, in the office, clinic, during group health education/support group sessions, or community location).
4. Assess developmental growth of infants according to the child's age.
The Family Outreach Worker will:
1. Conduct quarterly health education/support group sessions for interconception women, infants and fathers and/or male partners.
Outreach Services to the community.
The Family Outreach Worker (FOW) will participate in a minimum of 6 community events.
Progress in 2022-2023
Add progress for 2022 and 2023
What We Do
PCHD's Youth Development program serves middle school students in Pitt County. The goal to increase increase participants' knowledge, skills and behaviors for preventing unintended pregnancies.
Who We Serve
7th and 8th grade students who reside in Pitt County.
How We Impact
The program serves approximately 50 students each school year. Evidence-based curriculums are utilized to provide education, support and provide opportunities to serve the community.These strategies decrease the likely of getting pregnant. The program also introduces students to resources to help prevent unintended pregnancies.
Progress in 2022-2023
Our Youth Development Program was on pause due to COVID during the 20/21 school term. When schools reconvened for the 21/22 school term, we only serviced two schools. Now, with a new Adolescent Pregnancy Prevention Coordinator in place, collaborations with schools have been re-established and there are now plans to fully implement the program for the 24/25 School term.
Why Is This Important?
Well-being is a complex, multifaceted, and multilayered concept. There are many different approaches to defining and measuring well-being, and the focus and terminology used to describe these measures vary. Concepts that fall within the category of well-being include psychological wellbeing, emotional well-being, quality of life, health-related quality of life, psychosocial functioning, thriving, flourishing, happiness, satisfaction, and others.1 Life expectancy is one of those measures. It is also a proxy measure for the total health of a population. Disparities in life expectancy between populations point to where issues of health equity must be addressed.
Exercise is linked to positive physical, psychological, and social outcomes. Communities that create spaces for physical activity have healthier people with decreased risks of obesity, heart disease, and other chronic conditions that increase morbidity and mortality.
The prevalence of diabetes among US adults is 13.0%, affecting approximately 1 in 7 people (National Diabetes Statistics Report 2020). However, of those 13.0% only 10.2% are diagnosed. In Pitt County, diabetes increased from the 7th (seventh) leading cause of death to the 5th (fifth) among all races, and the 4th leading cause of death among African Americans (NCSCHS 2018). Continued efforts are needed to further decrease the impact of diabetes morbidity and mortality. Diabetes Self-Management Education and Support are key in moving this needle. Complications from poorly managed diabetes can be debilitating and deadly, but can be prevented or delayed through early detection and proper self-management. DSME programs have been shown to lower A1C, improve quality of life and reduce health care costs compared with usual care alone (ADA Standards of Medical Care 2017). In fact the 2021 ADA Standards of Medical Care indicates “…all people with diabetes should participate in diabetes self-management education (DSME) and receive the support needed to facilitate the knowledge, decision-making, and skills mastery necessary for diabetes self-care.”
What We Do
Pending description/development. 1/6/2023
Who We Serve
How We Impact
Description
Coordinated Approach to Child Health (CATCH) is a suite of programs designed to prevent childhood obesity and launch kids and communities toward healthier lifestyles. CATCH PE helps children identify and choose healthy foods and increasing moderate-to-vigorous physical activity. The CATCH My Breath program is a peer-led teaching approach that empowers students with the knowledge and skills needed to make informed decisions about e-cigarettes and resist social pressures to vape.
Partners
- CATCH Global Foundation
- Eastern Carolina Injury Prevention Program
- East Carolina University Department of Public Health
- ECU Health Medical Center
- Pitt County Health Department
- Pitt County Schools
- Pitt County School Nurse Program
- Pitt Partners for Health
Description
Kids In Parks is an expanding network of family-friendly outdoor adventures called TRACK Trails. Each TRACK Trail features self-guided brochures and signs that turn a kid’s visit into a fun and exciting outdoor experience. In Pitt County, there are four trails:
- Alice F. Keene District Park
- John Lawson Trail
- River Park North
- Trevathan Pond
Kids in Parks encourages and supports active family engagement, increases trail use, introduces recreational opportunities available in parks, forests and communities, and creates a network that offers an almost unlimited variety of experience. Each TRACK Trail features self-guided brochures and signs.
The benefits of outdoor play for children are dramatic and long lasting. From studies that show increased brain activity and higher SAT scores when children play in natural settings, to research that links a lower incidence of bullying, ADHD, and depression in kids that play outside, there is clear evidence that children benefit from spending time in nature. Increased physical activity decreases obesity, diabetes, ADHD, and other physical and mental ailments that are becoming too common with today’s sedentary lifestyle.
In addition, increased activity can also impact childhood obesity rates as a cost-effective intervention to address these issues.
TRACK Rx is a component of Kids in Parks that partners with doctors and health-care providers to place Kids in Parks materials in the hands of their patients. Partnering doctors prescribe outdoor activity to their patients called Park Rx, or Park Prescriptions.
For more information, please visit: https://www.kidsinparks.com/
Partners
- Community Schools and Recreation
- ECU Health Medical Center
- Kids in Parks
- Pitt Partners for Health
- Town of Grifton
- Town of Fountain
- Down East Diabetology
- Carolina Clinic for Health and Wellness
- Greenville Pediatric Specialist
- Farmville Pediatric Specialist
- Winterville Pediatric Specialist
Story Behind the Curve
Over the past few decades people have become increasingly disengaged with nature, spending less time in our parks and outdoor places, while spending more time “plugged-in” to electronic media. Recent studies show that on average kids spend 7.65 hours per day “plugged-in” and only an average of 7 minutes per day in unstructured outdoor play. The Kids in Parks program grew out of a vision to address these trends by getting kids “unplugged” and physically active in parks for their health and the health of our parks.
Likewise, parks benefit when people use them. Finding ways to create stronger connections between children and our parks cultivates current and future stewards who understand the value and appeal of our public lands. These stewards can be advocates for protecting our public lands from current and future threats.
While there are many parks, trails and outdoor areas already accessible to both urban and rural families, hiking and other outdoor activities are often perceived to be too difficult, potentially dangerous, or unexciting to newcomers. Kids in Parks is a proven program that gets beginners outside using a network of TRACK Trails established through partnerships with municipal, state, federal, and other partners to provide introductory level, family-friendly trails that are equipped with self-guided materials designed to make the experience more educational, enjoyable, and fun.
Description
Healthy Food pantry initiatives combine hunger relief efforts with nutrition information and healthy eating opportunities for individuals and families with low incomes. Such initiatives offer clients healthy foods such as fruits, vegetables, whole grains, low-fat dairy products, and lean proteins, and can implement client choice models. Healthy food initiatives can also modify the food environment via efforts such as on-site cooking demonstrations and recipe tastings, and healthy meal kits. Some food pantries and food banks establish partnerships with health and nutrition professionals to offer screening for food insecurity and medical conditions (e.g., diabetes), provide nutrition and health education, and health care support services as part of their healthy food initiatives.
Partners
- Catholic Charities
- Churches Outreach Network
- Food Bank
- Pitt County Cooperative Extension
- Pitt County Health Department
- Pitt County Farm and Food Council
- Pitt County Schools
- Pitt Partners for Health
What We Do
Pitt County Health Department's Diabetes Self-Management Education and Support (DSMES) Program aims to address burdens associated with diabetes.
1. Diabetes Self-Management Education - Educational sessions are led by Registered Dietitians (RDs) and Nurses based on an evidence-based curriculum. Educators work with patients to support informed decision-making, self-care behaviors, and active collaboration with the health care team.
2. Diabetes Support Group - A monthly support group is offered free of charge to assist persons with diabetes and those at risk. The goal is to implement and sustain behaviors needed to manage diabetes. Sessions include cooking demonstrations and interactive learning.
3. Medical Nutrition Therapy (MNT) - Nutritional counseling provided by a Registered Dietitian involves individualized food and physical activity plans which can aid in glucose, lipid and blood pressure control, weight goals and management of comorbidities.
4. Community Outreach - Interactive presentations are offered to community members regarding diabetes risk, prevention and management.
5. Collaboration with Medical Providers and Community - Ensures continuity of care between our program and others working with these clients.
6. Minority Diabetes Prevention Program (MDPP) - An evidence-based curriculum which teaches participants the behaviors necessary to treat pre-diabetes and help prevent development of type 2 diabetes.
Who We Serve
The Diabetes Self-Management Education and Support Program targets people with diabetes in Pitt County (as well as some other eastern NC counties). The current program serves primarily underserved and uninsured / underinsured populations.
How We Impact
Improve hemoglobin A1c, blood pressure, and lipids, enhance role of medications, reduce complications, and increase healthier lifestyle behaviors.
Progress in 2022-2023
The Diabetes Educator/Registered Dietitian left PCHD in 2023. Staff members from the Pitt County Wellness/Health Promotion Team are temporarily providing limited DSMES services in order to keep the program going until a new Program Coordinator is hired.
Description
Cooking Matters at the Store (formerly Shopping Matters) is a grocery store tour program that empowers participants with 4 key food shopping skills:
- Reading Food Labels
- Comparing Unit Prices
- Finding Whole Grain Foods
- Identifying three ways to purchase produce
Partners
- Share our Strengths
- ECU Health Medical Center
- ECU/BSOM medical students
- Local grocery stores
- Pitt County Health Department - Diabetes prevention program
- Pitt Partners for Health
Story Behind the Curve
In 2018, an estimated 2.4 million adults in North Carolina had prediabetes. In that same year, 12.1% of respondents to a Behavioral Risk Factor Surveillance System survey indicated that they had been told by a dcotor or other health professional that they had prediabetes or borderline diabetes. Of those respondents, 39.6% were racial and ethnic minorities (African Americans: 15.2%; Hispanic/Latinos: 11.1%; and other racial and ethnic minorities: 13.3%). (North Carolina State Center For Health Statistics, BRFSS 2018).
In 2020, nearly one-half of North Carolinians have diabetes, roughtly 12.5% of the population, or are at high risk for developing diabetes, approximately 34.5% of adults have prediabetes (North Carolina Diabetes Advisory Council Report 2020). It is also projected that over 3,000 people will die directly or indirectly because of diabetes and its complications, ranking North Carolina as 7th in the nation for diabetes related deaths (National Center for Health Statistics Report 2020).
The annual healthcare cost of diabetes in North Carolina is estimated to surpass $17 billion by 2025 (North Carolina Diabetes Advisory Council Report 2020).
Click here to visit the ENC Prevent Diabetes Facebook Page
From our interactions with participants, we find that while weight loss and physical activity is helpful, they experience many other benefits from the program. For example, some participants report improvements in HgbA1c, improved mobility, decreased need for medication, and improved self-esteem.
What We Do
NC MDPP is composed of three main components: (1) Community screenings for prediabetes and region-specific targeted marketing campaigns in minority communities promoting prediabetes and diabetes awareness, (2) 12-month NC MDPP Lifestyle Class Series in minority communities, (3) Community conversations to minority communities across North Carolina. NC MDPP Regional Collaboratives were created to engage, screen, and educate.
Who We Serve
The Minority Diabetes Prevention Program (MDPP) serves individuals who are at high risk for type 2 diabetes. Due to the health disparities among minority populations, MDPP focuses on enrolling African-American, Hispanic/Latino, American Indian, Alaska Native, Asian, Native Hawaiian, and other Pacific Islander community members. At least 50% of the participants enrolled in MDPP regionally must be from the minority population.
How We Impact
These 12-month, evidence-based programs can help people who have prediabetes or who are at high risk for type 2 diabetes make realistic and achievable lifestyle changes which can cut their risk of developing type 2 diabetes by up to 58% percent (CDC, “Preventing Type 2 Diabetes”).
The program helps with detection and treatment for prediabetes and helps slow the projected increase in type 2 diabetes prevalence and expenditure in North Carolina.
Description
Why Is This Important?
Description
ECU Health Medical Center engages with community partners to improve access to culturally appropriate mental health services for individuals living in Pitt County. Building Resilience and Courage to Excel (BRACE) is an initiative that leverages a team of professionals and invested community leaders who meet monthly to address trauma through systemic and organizational change and community education.
Partners
- East Carolina University
- TEDI Bear Advocacy Center
Description
Community Health Program utilizes innovative approaches and evidenced-based programs to provide vaping education through targeted community and school education initiatives.
Partners
- Eastern Carolina Injury Prevention Program
- ECU Health School Health Program
- Pitt County Health Department
- Pitt County Schools
Progress on CHIP
Pitt County Health Department is monitoring progress on its priorities through the programs and performance measures list below. Click on the links for progress made in 2022.
Priority Area: Maternal & Child Health:
Women, Infants and Children Program (WIC)
Cribs for Kids - Safe Sleep Education
Youth Development/Adolescent Pregnancy Prevention Program
Parks and Facilities of Pitt County Wayfinding App
Coordinated Approach to Child Health (CATCH)
Priority Area: Chronic Disease Prevention:
Diabetes Self-Management Education and Support
Cooking Matters at the Store (CMATS)
Minority Diabetes Prevention Program-PCHD
Priority Area: Mental/Behavioral Health
Morbidity and Mortality Changes Since Last CHA
Maternal and Child Health
The infant mortality rate, the rate of infant deaths per 1,000 live births, is a common measure of maternal and child health, the community’s overall health and well-being that also tells the important story of equity within our community. Infant mortality is defined as the death of a child before their first birthday.
In 2019, Pitt County’s total infant death rate increased dramatically to 11.5 / 1,000 live births. The previous year’s (2018) total infant mortality death rate was 6.7 / 1,000 live births compared to 8.8 / 1,000 live births in 2017. Pitt County’s 2019 total infant death rate was almost double that of North Carolina’s total infant death rate of 6.8 / 1,000 live births.
County Health Rankings & Roadmaps
https://www.countyhealthrankings.org/health-data/north-carolina/pitt?year=2022
Pitt County Health Outcomes
Health Outcomes represent how healthy a county is right now. They reflect the physical and mental well-being of residents within a community through measures representing not only the length of life but quality of life as well.
Pitt is ranked in the higher middle range of counties in North Carolina (Higher 50%-75%).
Pitt County Health Factors
There are many things that influence how well and how long we live. Everything from our education to our environments impact our health. Health Factors represent those things we can modify to improve the length and quality of life for residents. They are predictors of how healthy our communities can be in the future.
Pitt is ranked in the higher middle range of counties in North Carolina (Higher 50%-75%).
Emerging Issues Since Last CHA
New/Paused/Discontinued Initiatives Since Last CHA
Progress on CHIP
Pitt County Health Department monitors progress on the commuity priorities through these programs:
Women, Infants and Children Program (WIC)
Cribs for Kids - Safe Sleep Education
Youth Development/Adolescent Pregnancy Prevention Program
Parks and Facilities of Pitt County Wayfinding App
Coordinated Approach to Child Health (CATCH)
Diabetes Self-Management Education and Support
Cooking Matters at the Store (CMATS)
Minority Diabetes Prevention Program-PCHD
Morbidity and Mortality Changes Since Last CHA
Emerging Issues Since Last CHA
New/Paused/Discontinued Initiatives Since Last CHA
The following programs are new:
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