Partnerships

*Current & Former: CHIP Leadership and Data Team

Executive Summary

Buncombe County ranks 19th out of 100 counties in NC based on more than 30 measures of how healthy residents are and what will impact their future health (County Health Rankings, 2022).

Primary and secondary data show that health focus areas, especially heart disease and diabetes, birth outcomes, and mental health and substance use disorder, adversely impact the community as a whole and disproportionately and significantly impact community members who are historically marginalized. Black/African American, Hispanic/Latin/Latinx, Indigenous/First Nation and those with low incomes are more likely to have poorer health outcomes, lower high school graduation rates, higher food and housing insecurity, increased hazardous environmental risks, and more limited access to economic and social development opportunities (NCOMHHD, 2018).

In 2020, Buncombe County (BC) Commissioners declared, “Racism a Public Health and Safety Crisis (BCG, 020)” to acknowledge and address the impacts that persistent structural racism in public policy, institutional practices and cultural norms have on the root causes of health and social-economic disparities for populations of color (NCIOM, 2020). The declaration links the social determinants of health (SDoH), to how historical and continued systemic racism shape the structure of communities, social and economic opportunities, and access to resources, wealth, and power. The SDoH, those conditions in the community where people live, learn, age, work, play, worship are structurally designed by public policy, drive 80% of health outcomes and highly correlate with race, age, gender, and income (CDC, 2021; NCIOM, 2020). By focusing attention on the root causes of health and life course disparities, the 2021 CHA aligns strongly with and supports the BC Commissioner’s Declaration of Racism as a Public Health and Safety Crisis, the BC Strategic Plan 2020-2025 and the BC Racial Equity Action Plan.

Priorities

The 2021 Buncombe County CHA health priorities/health focus areas were identified due to common underlying or root causes for health inequities related to systemic racism, oppression, and trauma.

• Birth Outcomes & Infant Mortality - significant disparties are present in birth outcomes, infant mortality, and preconception health for Black/African American and Hispanic/Latin/Latinx residents of Buncombe County
• Mental Health & Substance Misuse - trending increase of reported mental health symptoms (depression and suicidal ideation/thoughts), and continued increase in drug overdose related deaths
• Chronic Disease: Diabetes & Heart Disease - significant disparities are present in mortality and morbidity rates for Black/African American and Hispanic/Latin/Latinx Buncombe County residents

Public Health Framework

The Buncombe County CHIP Data Team and CHIP Advisory Council utilize an overarching public health framework centered on Social Determinants of Health (SDoH), anti-racism, and the application of a life course perspective to identify underlying or root causes for health disparities within Buncombe County. The most prominent and influential root causes identified during data analysis were systemic racism, oppression, and the pair of Adverse Childhood Experiences (ACEs) and Adverse Community Experiences. More specifically, the impact of trauma exposure epigenetically (generationally and historically), in utero, early life, and throughout the life course, has a weathering effect resulting in poorer health outcomes and premature deaths for Black, Indigenous, and People of Color (BIPOC), persons with marginalized identities and low income.

2022 Progress on CHIP

Buncombe County Reparations Committee

In 2020, Buncombe County Board of Commissioners and Asheville City Council passed a resolution in support of Reparations for Black residents. As a result of the resolutions, a Reparations Commission was created in order to provide both the City and County with short, medium, and long-term recommendations.  Since the creation of the commission, Impact Focus Area (IFA) Workgroups have been developed to assess the following areas: education, health & wellness, housing, economic development, and criminal justice. The IFA’s will work to develop a set of recommendations based on the review of policies, and existing data to ensure all harms and unfair practices are discontinued. Two recommendations have already been brought forth. The first recommendation was for both Buncombe County and the City of Asheville to incorporate reparations into all future budgets. Second, the commission recommended the hiring of an external audit team to conduct internal audits for both the City and County to review policies and practice to ensure no further harm. Both recommendations have been accepted, and the Commission is in the process of developing a Scope of Work in order to release a request for proposals. 

Buncombe County Government's Racial Equity Action Plan

As one facet of the Buncombe County Racial Equity Action Plan, the Buncombe County MEET (meaningfully engaging equity together) Team was created to facilitate and enhance anti-racist learning initiatives for Buncombe County. In 2022 the MEET Team facilitated 80 hours of equity and inclusions courses via four modules presented 10 times each for all County employees. The MEET Team worked with 258 County employees, had a total of 915 people attend the 36 modules, and spent 156 hours preparing for trainings (not including content creation, team education, and other necessary prep outside of team meetings).

2023 Progress on CHIP

Reparations Commission & Cease the Harm Audit

As part of the City of Asheville and Buncombe County’s commitment to ending the harms against the Black/African American community an RFP application was released in search of a third-party audit team. Ultimately, the Carter Development Company based in Florida was selected to lead an audit of both the City of Asheville and Buncombe County to assess and identify any policies or practices which perpetuate harm against the Black community. The audit consisted of cohort meetings with City and County staff and the review of artifacts. Upon analysis, the Carter Development Group identified over 70 preliminary recommendations across the seven focus areas including Health & Wellness, Economic Development, Housing, Education, and Criminal Justice. In January 2024, the Carter Development group presented some of their findings to the Reparations Commission.

Partners

Partners With A Role to Play

• Buncombe County CHIP Advisory Council members/agencies

Actions and Accomplishments

Supporting Cross-sector Collaboration to Undo Racism was identified by community members, partners, and our CHIP Advisory as an ongoing CHIP strategy, that when combined with other actions in our community, has a reasonable chance of making a difference in health equity outcomes in our community. The priority population for this Cross-sector Collaboration to Undo Racism are community institutions, organizations, and providers whose work influences health outcomes.

Cross-sector Collaboration to Undo Racism aims to make a difference at multiple levels: individual/interpersonal behavior; organizational/policy; and environmental change level. This strategy is focusing on addressing root causes of health inquities, recognizing the role of our institutional policies, practices,
cultures, norms, and behaviors in impacting and perpetuating health inequities between racial and ethnic groups in our
community.

Process for Selecting Priority Program/ Strategies

The following actions have been identified by our CHIP Advisory and Leadership Team and community members as ideas for what can work for our community to make a difference on racial equity.

Actions and Approaches Identified by Our Partners 

These are actions and approaches that our partners think can make a difference on racial equity:

• Apply and require a robust (and recurring) racial equity training for all healthcare providers
• Increase awareness, funding, prevention, and intervention on Root Causes of health disparities
• Utilize a racial equity lens for evaluating everything, including policies, programs, trainings, environment, etc. 
• Expand community involvement in designing and implementing programs and services
• Fund local organizations to do policy evaluations, co-design of trainings, walk-throughs of spaces, conduct environmental assessments, etc.
• Support collective impact between grassroots community-led organizations and bigger community agencies

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference on racial equity:

• Safety and Justice Challenge 
• City MatCH Equity Institute
• Racial Equity and Inclusion - Groundwater trainings, City and County positions focused on equity
• Disaggregating all data to reflect the authentic realities for all people in a community, group, etc. vs. focusing on the whole or aggregate data

What Community Members Most Affected by Racism Say 

These are the actions and approaches recommended by members of our community who are most affected by racism and discrimination:

• Reuire robust and ongoing professional development curriculums focused on anti-racist practices for healthcare and social service providers
• Reparations
• Hiring and retaining more BIPOC providers in healthcare and social services via creating and sustaining an organizational culture that is anti-racist

Additional Resources

National Equity Atlas (PolicyLink)

Government Alliance on Race and Equity (GARE)

Evidence Base

Primary and secondary data consistently show that the Buncombe County 2021 Commuity Health Assessment (CHA) health focus areas: heart disease and diabetes, birth outcomes, and mental health and substance use disorder, adversely impact the community as a whole and disproportionately and significantly impact community members who are historically marginalized. Black/African American, Hispanic/Latin/Latinx, Indigenous/First Nation and those with low incomes are more likely to have poorer health outcomes, lower high school graduation rates, higher food and housing insecurity, increased hazardous environmental risks, and more limited access to economic and social development opportunities.

In 2020, Buncombe County (BC) Commissioners declared, “Racism a Public Health and Safety Crisis” to acknowledge and address the impacts that persistent structural racism in public policy, institutional practices and cultural norms have on the root causes of health and social-economic disparities for populations of color. The declaration links the social determinants of health (SDoH), to how historical and continued systemic racism shape the structure of communities, social and economic opportunities, and access to resources, wealth, and power. The SDoH, those conditions in the community where people live, learn, age, work, play, worship are structurally designed by public policy, drive 80% of health outcomes and highly correlate with race, age, gender, and income.

By focusing attention on the root causes of health and life course disparities, there is strong community and government alignment with Buncombe County Commissioner’s Declaration of Racism as a Public Health and Safety Crisis, the Buncombe County Strategic Plan 2020-2025, and the Buncombe County Racial Equity Action Plan.

Evidence-Based Strategies 

These are actions and approaches that have been shown to make a difference on racial equity and health equity outcomes.

2022 Progress on CHIP

Buncombe County Behavioral Health & Justice Collaborative

Buncombe County’s Behavioral Health and Justice Collaborative (which formed in 2021) continued to meet regularly througout 2022 to assess the County’s crisis response service array. In 2022 the group began examining data and service utilization trends and soliciting feedback from community members and organizations, in order to engage in strategic planning to identify and priority rank the identified models and initiatives for local implementation. Throughout most of 2022, the group utilized meeting time to work on strategic planning and recommendations for opioid settlement funding, including various sub-committees focused on establishing a robust research narrative on root causes, and development of goals, strategies, and performance measures. In 2023, the group will pivot slightly to refocus on behavioral health and crisis strategic planning and recommendations for future initiatives.

* Proposed/Upcoming initiative: 911 Nurse Triage line (tentatively FY25)

CARE Team

The Buncombe CARE Team continued to meet regularly in 2022 to strategize with community members, providers, and those with lived experience around substance use and harm reduction initiatives in Buncombe County. A new leadership advisory group was formed in the Fall of 2022 to further support the CARE Team’s strategic planning and initiatives, some of the focus areas include: prevention education, outreach, media/awareness, and policy change with a focus on safe, evidence-based recovery housing. In early 2023, CARE Team leadership and HHS staff will be facilitating a lunch and learn event for Buncombe County employees on available harm reduction services, provide access to free reversal kits, and train on how to administer Naloxone in the event of an overdose.

National Alliance to End Homelessness: Within Reach Ending Unsheltered Homelessness in the Asheville-Buncombe Continuum of Care (COC)

The City of Asheville, Buncombe County, and Dogwood Health Trust contracted with the National Alliance to End Homelessness to assess Buncombe County’s community needs related to housing and to develop a formal report with recommendations to support ongoing work within Buncombe County to end houselessness.

The specific recommendations outlined in the report included:

• Improve system governance
• Implement an encampment resolution policy
• Build street outreach capacity
• Increase crisis response capacity
• Implement system improvements to the coordinated entry system (data systems)
• Create a high-utilizer targeted initiative
• Promote a housing surge for unsheltered people
• Implement moving on strategies (for those phasing out of supporting housing services)

Buncombe County State of Housing Insecurity & Houselessness (National Alliance to End Homelessness, 2022)

• The National Alliance to End Homelessness report identified that in January 2022, there were 637 individuals experiencing houselessness during the designated day for the Point In Time (PIT) count, which is a 16% increase from 2020. 
• There has been a 21% increase in overall houselessness in Buncombe County from 2020 to 2021.
• Of those experiencing houselessness in Buncombe County during the January 2022 PIT count, 24% were Black/African American (Black/African American’s make up 6% of the Buncombe County population), which indicates that Black/African American Buncombe County residents disproportionately experience houselessness compared to White residents.
• More broadly, there were 17,000 Buncombe County renters/households that were cost burdened in 2022, meaning that the household pays more than 30% of their total income towards housing – cost burdened households are more vulnerable to falling into houselessness.
• Rental costs in Asheville have increased by more than 40% since the start of the COVID-19 pandemic.
• The County-wide rental vacancy rate is less than 4% and City-wide rental subsidy rate is less than 3%, meaning that locating rental housing, particularly affordable, income-based rental housing, is nearly impossible.
• There are currently not enough emergency shelter beds to adequately support the community’s need for safe shelter (there were 293 year-round beds available – but only 105 of those beds are available to non-veteran adults who are single)

Buncombe County is set to receive $16 million over a period of 18 years through the Opioid Litigation Settlement. Communities will be able to use these dollars to help attain outcomes for residents through treatment, recovery, harm reduction, and other life-saving programs and services. Last year, Buncombe County personnel worked with a concentrated team of professionals and community members with proximate experience to opioid and substance use-related harm in our community to create a list of short-term spending priorities, while also beginning the process of exploring longer term strategic approaches to capitalize on this unique funding opportunity.

Short-term priorities that were identified through this community engagement process included support for Buncombe County’s Community’s Paramedicine teams, Syringe Service Program (including enhanced community collaboration to broadly distribute Narcan throughout the county), medication assisted treatment (MAT), and re-entry programs through the Justice Resource Center. Seeking to look further ahead, a strategic planning process launched in September of 2022 engaged multidisciplinary stakeholders to conduct root cause analysis, identify key indicators for monitoring & evaluation planning, and conduct community outreach including surveying efforts to hear from residents across the County, those actively receiving care in treatment facilities, as well as from currently incarcerated individuals inside the Buncombe County Detention Facility. This planning cycle is nearing completion as County administrators prepare to bring recommendations for funding priorities for Fiscal Years 2024-2026 to the Board of Commissioners consideration in March 2023.

2023 Progress on CHIP

Buncombe County Sheriff’s Office Co-Responder Program

During the summer, Buncombe County Sheriff’s Office piloted a program in partnership with the Community Paramedic Program which paired mental health professionals with police officers to respond to calls of potential mental health crises and or substance use related calls. The goal of the program is to prioritize connecting individuals with the appropriate resources and care. During the pilot program the Co-Responder Team were able to assist with 191 calls in which no arrests were made.

Alignment

Equity in Birth Outcomes & Infant Mortality - or "Birth Equity" for short - and the related result are aligned with the following Healthy NC 2030 Indicators.

• Reduce the infant mortality racial disparity between whites and African Americans
• Access to prenatal care

Experience and Importance

How would we experience this result in our community if we are successful?
Our community partners identified the following themes as key elements of our desired result:

• Healthy babies: 100% healthy births (full term, healthy weight, no infant deaths)
• Healthy parents: Healthy, supported mamas and babies. Parents feel empowered with emotional well-being. Supported, educated, and engaged fathers/partners.
• Healthy community: Thriving safe community where everyone gets along, & has what they need to be healthy. Household stability. Health care for all. Reparations made.

If we achieved our desired result, we would feel:

• Peaceful, with more time and energy to engage with community
• More relationship driven
• People listening to each other & respecting each other
• Less stress
• Families can earn a real living wage to live in Asheville
• No drugs, alcohol, vandalism
• Respect, honoring each other
• Emotional and physical safety
• Less fear
• Children can safely play outside with their friends
• More connection with nature
• Less coal ash
• Less light polution
• More edible gardens
• Quiet - no sirens
• Nicer police
• History of structural racism has been reconciled and repaired

Narrative

Equity in Birth Outcomes and Infant Mortality was one of 5 standout health conditions based on the size and severity of the issue in
our community.

In utilizing a public health life course approach,racial and ethnic disparities in birth outcomes and infant mortality can be strongly correlated with the transfer of historical and cumulative racial trauma intergenerationallyand also the present lifetime exposure to systems that are rooted in racism and discrimination. These disparities are further compounded when early life experiences expose infants and young children (and their developing brains and nervous systems) to adverse childhood and community stressors with limited opportunities for experiences that build resilience. Relatedly, public health research has continued to highlight that individuals who experience systemic oppression, racism, a high pair of ACES exposure, and barriers to accessing health resources face significant challenges to health equity throughout their lifetime (Geronimus, et al, 2006).

More specifically, racism accounts for the disparities of Black/African American birthing outcomes even when Black/African American birthing women/individuals are highly educated, have access to pre-natal care, and do not have underlying health conditions. Black/African American mothers and birthing individuals often experience negative health impacts during pregnancy and post-partum, primarily due to factors outside of their control (i.e., experiences of intergenerational trauma, pair of ACES, and the eroding effects of systemic racism and white supremacy culture) – studies have continued to see these disparities even when accounting for age and socio-economic status across groups (Burris & Hacker, 2017). What this means is that Black, Indigenous, and babies of color not only encounter the cumulative harms of interacting with and living within racists systems across their lifetime, they also have an increased likelihood of in utero exposure to toxic stress due to the historical and intergenerational trauma of racism in the United States.

Secondary data revealed significant disparities in are present in birth outcomes, infant mortality and preconception health for African American and Latinx residents.
 

Key findings related to Birth Equity included:

Access to Pre-Natal Care (NCSCHS, 2021b)

 • 85% of White pregnant individuals, 77% of Black/African American, and 76% Hispanic/Latin/Latinx individuals accessed prenatal care in the first 1-3 months of pregnancy

Low Birth Weight (NCSCHS, 2020b)

• 9% of births in Buncombe were classified as low birth weight (under 2,500 grams)

• 1% of births in Buncombe were classified as very low birth weight (under 1,500 grams)

 Pre-Term Births (NCSCHS, 2020b)

• Pre-term births (less than 37 weeks gestation) in Buncombe for 2014-2018 was 10% vs. 90% of births (37+ weeks of gestation)

Infant Morality (NCSCHS, 2021d)

o Overall infant mortality rate in Buncombe is 4.8 for 2015-2019 compared to 5.1 for 2014-2018

o For the period of 2014—2018 there were 38 White babies that died, 15 Black/African American babies that died, and 9 Hispanic/Latin/Latinx babies that died.

Burris HH, Hacker MR. Birth outcome racial disparities: A result of intersecting social and environmental factors. Semin Perinatol. 2017 Oct;41(6):360-366. doi: 10.1053/j.semperi.2017.07.002. Epub 2017 Aug 18. PMID: 28818300; PMCID: PMC5657505

Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. American journal of public health, 96(5), 826–833. https://doi.org/10.2105/AJPH.2004.060749

Partners

Partners With A Role to Play

• CHIP Advisory Council members and organizations
• YWCA-Asheville
• Project Nurturing Asheville and area Families (NAF) – Mount Zion Community Development
• Asheville Buncombe Institute for Parity Achievement (ABIPA)
• Sistas Caring for Sistas (SC4S)
• MAHEC
• Buncombe County Women, Infants, and Children (WIC) services
• BC Care Management & Nurse-Family Partnership
• Buncombe County Schools
• Asheville City Schools
• Buncombe County Partnership for Children
• Perinatal Emotional Support Network 

Actions and Accomplishments

The overall approach used was a modified Results-Based Accountability process. A community input process was facilitated using the RBA Whole Distance Exercise framework with multiple events held in partnership with community providers to listen to community voices. These input sessions included over 75 individuals including those with lived experience, health care providers, social service agencies, advocacy  organizations and local non-profits. The professionals participating included those working in the health field as well as those working to address many of the social and economic factors that impact health.

The following actions have been identified by our CHIP Advisory and Leadership Team and community members as ideas for what can work for our community to make a difference on Birth Equity in Buncombe County.

Actions and Approaches Identified by Our Partners 

These are actions and approaches that our partners think can make a difference:

• Providing services that are culturally humble and trauma-informed
• Addressing root causes of poverty
• Creating health systems that are affordable 

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference:

• Home visitation and case manager programs
• Collaboration amongst organizations to broaden impact 

Additional Resources

Evidence Base

Healthy People 2030 Evidence-Based Practices: "Centers for Disease Control and Prevention Grand Rounds: Public Health Strategies to Prevent Preterm Birth"

Strategies that prevent preterm birth and potential complications"

• Increase women and birthing people's access to preconception care services.
• Identify women and birthing people at risk for preterm delivery and provide access to effective preventive treatments.
• Discourage deliveries that aren't medically necessary, especially before 39 weeks.

Shapiro-Mendoza, C. K. (2016). CDC grand rounds: public health strategies to prevent preterm birth. MMWR. Morbidity and mortality weekly report, 65.

What We Do

https://www.buncombecounty.org/governing/depts/health/Nutrition.aspx

2022 Progress on CHIP

• https://www.ncdhhs.gov/media/19127/download?attachment
• *NOTE: The most current participation data that has been verified by the state is through September 2022.
  • Women participating in Buncombe County WIC through September 2022:  1082
  • Infants birth to 1 year age participating in Buncombe County WIC through September 2022: 1004
  • Children aged 2-5 years participating in Buncombe County WIC through September 2022: 2700

2023 Progress on CHIP

• https://www.ncdhhs.gov/divisions/child-and-family-well-being/community-nutrition-services-section/wic/staff/wic-local-agency-resources/nc-wic-agreement-addenda-data
• *NOTE: The most current participation data that has been verified by the state is through November 2023.
  • Women participating in Buncombe County WIC through November 2023: 946
  • Infants birth to 1 year age participating in Buncombe County WIC through November 2023: 976
  • Children aged 2-5 years participating in Buncombe County WIC through November 2023: 2,139

What We Do

https://www.ywcaofasheville.org/what-we-do/empowering-women/motherlove/

2022 Progress on CHIP

The YWCA is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom, and dignity for all. The YWCA’s Women’s Empowerment Department provides services for women of childbearing age via its Getting Ahead and MotherLove programs. Getting Ahead supports women living in poverty to build resources for a more prosperous life. MotherLove provides mentoring and support for pregnant or parenting teens, building skills as strong parents and successful students with the goals of ensuring participants graduate high school, enroll in secondary education, deliver a healthy baby, and delay a subsequent pregnancy.

MotherLove program participants continue to engage with a modified service delivery model due to COVID-19 restrictions on group events held within school buildings. Each participant continues to receive case management and referral supports related to pregnancy and post-partum risks and needs. None of the Motherlove participants have experienced a repeat pregnancy and all remain engaged in case management service to support with social determinants of health needs.

2023 Progress on CHIP

MotherLove programming has continued throughout 2023 as they work to re-establish support services within local schools. Program participants have engaged in case mangement services, with 100% acessing prenatal care and education around healthy pregnancy, and 100% delivering at 37+ weeks of gestation. In 2023, programming also became accessible to participants who would have previously "aged out" at 18 years in an effort to expand support services for new and expecting parents. 

What We Do

https://buncombepfc.org/about-us/who-we-are/?gclid=EAIaIQobChMI9Oyl0MmG_AIVRuTICh13BgFKEAAYASAAEgJO3PD_BwE

2022 Progress on CHIP

The Buncombe County CHIP Advisory is working to improve birth outcomes and reduce the rate of infant mortality.  As breastfeeding is an important strategy to improving child and maternal health, community partners are working together to achieve designation as a breastfeeding friendly community by completing the Ten Steps The Breastfeeding-Family-Friendly Community Designation (BFFCD), as articulated by the Carolina Global Breastfeeding Institute. In 2022 there were 15 agencies engaged in the the process to receive breastfeeding friendly designation. The process for designation is long and can be complicated, which has been noted as a potential barrier for expanding the work moving forward.

2023 Progress on CHIP

Funding to support Breastfeeding Friendly designations ended after fiscal year 2022. However, FY 2023 Buncombe County Partnership for Children received funding to continue to support the work of the Breastfeeding Coalition in Buncombe County. Currently, the coalition is working to help expand breastfeeding resources and education.

What We Do

https://www.buncombecounty.org/Governing/Depts/Health/nfp.aspx

2022 Progress on CHIP

• The Nurse-Family Partneship program supported with 66 births in FY22, and 58 of those had a postnatal assessment from the first six weeks of birth
• There were 39 babies who were born 39 weeks or later, all of them weighing over 5 lbs 8 ounces
•  There were 80 participants enrolled in in 2022 receiving 246 visits/services
• There were 72 Nurse-Family Partnership graduations in 2022 for families who have completed services and no longer need supports

2023 Progress on CHIP

• The Nurse-Family Partnership program supported with 91 births in FY 23
• There were 9 babies (9.8%) born 37 weeks or later, all of them weighing under 5 lbs and 8 ounces
• There were 10 babies (10.98%) born prematurely (before 37 weeks)
• Nurse-Family Partnership graduation rate for 2023 was 70.59%

What We Do

https://circleofsecuritynetwork.org/the_circle_of_security.html

2022 Progress on CHIP

Trainings for COSP are now being held regularly for Buncombe County parents, caregivers, and a wide variety of service providers in order to support healthy parent/caregiver-child attachment and attunement. Participants who engage in the 8-week training series complete a survey after the final session to assess their knowledge and behavior change related to understanding the child’s bids for attention and the underlying emotional need, as well as the impact of the adult/caregiver’s childhood and lifetime experiences on interpreting the emotional needs of the child. A process to access county-specific data on the identified CHIP metrics for the COSP program are underway and performance measure updates should occur by June 2023.

2023 Progress on CHIP

COSP trainings have continued throughout 2023 in Buncombe County. In June 2023, longitudinal training outcomes data was compiled and shared for updates in the identified performance measures. The outcomes data was collected from October 2020 through June 2023 from 205 parents/caregivers and 50 early childhood professionals. Early childhood professionals participating in these Circle of Security Parenting groups included: early educators; early intervention staff and service providers, including Children’s Development Service Agency (CDSA) staff working with parents and educators of birth to three-year olds; child welfare professionals; mental health providers; and in-home visitors. Additional Circle of Security Parenting groups have been offered to parents, caregivers, and early childhood professionals in Buncombe County during this period. The numbers reflect only the evaluations collected in a centralized data system and do not include participants in all groups. Efforts continue to increase the number of COSP facilitators using the centralized system.

More information about the Circle of Security Parenting program can be found at the Circle of SecurityInternational website at www.circleofsecurityinternational.com.

Alignment

Mental Health & Substance Misuse and our related result are aligned with the following Healthy NC 2030 Indicators:

• Reduce the suicide rate (per 100,000 population).
• Drug overdose/poisoning deaths

Experience and Importance

How would we experience this result in our community if we are successful?

• Access and ability for all people in Buncombe County to attain safe and affordable homes
• Social connection/cohesion across communities
• Free transportation 
• No ageism (especially with providers)
• No stigma
• Healthy intergenerational relationships
• Access to mental health care
• Equity exists - no discrimination - inclusive communities
• Accountability and commitment from systems and funders
• Dismantle hierarchical systems
• Less gatekeeping services
• Systems that empower
• Self-advocacy to meet needs
• Equitable opportunities
• Resiliency/strengths are honored and celebrated
• Acceptance of mental health as part of whole-person health
• Hope that things can change and improve
• No overdose deaths
• Readily accessible/available overdose reversal and drug testing kits

What information led to the selection of Mental Health & Substance Misuse and this related result?
Mental Health and Substance Misuse were one of 5 health conditions based on the size and severity of the issue in our community. Both primary and secondary data sources were compiled to support with size, severity, and feasibility. The Buncombe County CHIP Advisory Council, with representation from 40+ community organizations, were actively engaged in multiple monthly work sessions to identify which community health conditions to prioritize based on relevance, impact and feasibility.

Key findings related to Mental Health & Substance Misuse included:

• 27% of Buncombe County survey respondents identified having more than seven days of poor mental health in the last month (an 8% increase from the 2018 Buncombe CHA)
• 42% of Buncombe County survey respondents have experienced symptoms of Chronic Depression (compared to 33% from 2018 Buncombe CHA and 30% in the United States)
• 13% of Buncombe County survey respondents identified that they were dissatisfied or very dissatisfied with life (a 4% increase from the 2018 Buncombe CHA)

Access to Services/Care

• 25% of Buncombe County survey respondents identified they were unable to access needed mental health care or counseling in the past year, which is an 8% increase from the 2018 Buncombe CHA 

Mental Health-Related Emergency Department Visits (Anxiety, Depression, and Self-Harm

• 9% of White Buncombe County survey participants, 8% of Black/African American participants, and 16% of Hispanic/Latin/Latinx participants identified having suicidal thoughts in the last twelve months 

Alcohol Use & Dependency

•  61% of Buncombe County survey respondents identified as current drinkers which is a 9% increase from the 2018 Buncombe CHA 
• 23% of Buncombe County survey respondents identified themselves as heavy drinkers (compared to 18% for the WNC region and 15% for North Carolina)
• 24% of White Buncombe County survey participants, 17% of Black/African American participants, and 24% of Hispanic/Latin/Latinx participants identified themselves as binge or heavy drinkers

Substance Misuse

• 118 Buncombe County residents died due to drug overdose in 2021
• 108 Buncombe County residents died due to drug overdose in 2020

Narrative

Mental Health and Substance Use/Misuse: trending increase of reported mental health symptoms (depression and suicidal ideation), continued increase in drug overdose deaths

Population health data continues to reflect that mental health and substance use are a growing public health crisis across the nation, and local data supports similar levels of urgency in Buncombe County. In applying a socio-economic perspective and life course framework to mental health and substance use, the underlying or root causes of these health inequities becomes clearer. When examining mental health through the lens of racial equity, research demonstrates that exposure to racism through structural and systemic oppression is as much of a significant health indicator as exposure to discrimination (Williams, 2019). More specifically, the experience of racism is a root cause for health disparities, not an individual’s racial or ethnic identity. Given the root causes for diseases of despair, there is also a clear connection between an individual’s exposure to Adverse Childhood Experiences and Adverse Community Environments (the pair of ACEs) and systemic racism and oppression on health outcomes.
Decades of research on Adverse Childhood Experiences has demonstrated that an individual’s exposure to traumatic events increases the risk of substance use/abuse, which has since supported a shift towards trauma-informed treatment and services (Philippa, et al, 2011). This shift in treatment focus highlights the importance of trauma-informed and resiliency-based interventions – meaning the focus is now shifting to understanding the events, circumstances, and systems and environments (social determinants of health) that have caused harm to an individual, rather than placing unreasonable responsibility on an individual for circumstances which are heavily influenced by social and environmental determinants of health and often outside of their control.

At a population level, this looks like dismantling oppression and racism in all policies and systems, and on a community or local level this involves rebuilding mental health and substance use services and interventions that are culturally sensitive and trauma informed. This shift to providing evidence-based harm reduction interventions that center around meeting an individual “where they are” and creating opportunities for authentic connection and resiliency continue to show promising outcomes.

Philippa L. Farrugia, Katherine L. Mills, Emma Barrett, Sudie E. Back, Maree Teesson, Amanda Baker, Claudia Sannibale, Sally Hopwood, Sabine Merz, Julia Rosenfeld & Kathleen T. Brady. (2011). Childhood trauma among individuals with co-morbid substance use and post-traumatic stress disorder. Mental Health and Substance Use, 4(4), 314-326, DOI: 10.1080/17523281.2011.598462

Williams D. R. (2018). Stress and the mental health of populations of color: Advancing our understanding of race-related stressors. Journal of Health and Social Behavior, 59(4), 466–485. https://doi.org/10.1177/0022146518814251

Partners

Partners With A Role to Play

• CHIP Advisory Council members and organizations
• WNC Healthy Impact
• Buncombe County Emergency Management Services (EMS) – Community Paramedicine and Post-Overdose Response Teams
• Community Harm Reduction providers – community reversals *To be further defined
• Opioid Settlement planning/funding *This is still in planning phase
• Buncombe County Compassion Access Recovery Education (CARE) Team 
• Community-based Crisis Services *This is still in planning phase
• Buncombe County EMS – Community Paramedicine/Post-Overdose Response Team
• Harm Reduction Providers – community reversals *To be further defined
• Community-based peer support specialists *To be further defined
• Sunrise Community for Recovery & Wellness
• Umoja Health, Wellness, and Justice Collaborative
• Appalachian Mountain Community Health Services
• MAHEC
• Institute for Preventive Healthcare & Advocacy

Actions and Accomplishments

The overall approach used was a modified Results-Based Accountability process. A community input process was facilitated using the RBA Whole
Distance Exercise framework with multiple events held in partnership with community providers to listen to community voices. These input sessions included over 75 individuals including those with lived experience, health care providers, social service agencies, advocacy
organizations and local non-profits. The professionals participating included those working in the health field as well as those
working to address many of the social and economic factors that impact health.

The following actions have been identified by our CHIP Advisory and Leadership Team and community members as ideas for what can work for our community to make a difference on mental health and substance misuse in Buncombe County.

These are actions and approaches that our community partners and Buncombe County residents, including those directly affected by Mental Health and Substance Misuse, say it would take to do better:

These are actions and approaches that our partners think can make a difference:

• Supervised safe-use sites
• Expand access to Medication Assisted Treatment (MAT) 
• Safe, affordable permanent housing
• Engaging youth in community-based organizations
• Refocus housing and food as basic human needs = accessible for all
• Addressing systemic racism with policy and practice standards
• Expand free/lowcost MH services, including Medicaid expansion
• Integrating community health workers into treatment teams
• Policy-wise: increase reimbursement cost for clinicians providing licensed support groups
• Policy-wise: Create open access for private providers to offer services.
• Policy-wise: raise the minimum wage; the cost of living in this area makes it difficult to gain economic independence and stability
• Expand funding for childcare
• Expand insurance coverage for children and reduce co-pays
• Strengthen prevention and early intervention supports that focus on healthy attachment
• More systemic advocacy for policy changes 

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference on mental health and substance misuse:

• Community Paramedicine & Post-Overdose Response Teams
• Harm Reduction - Syringe Exchange Programs
• WNC Listening Line
• Resources for Resiliency

What Community Members Most Affected by Mental Illness and Substance Misuse Say 

These are the actions and approaches recommended by members of our community who are most affected by mental illness and substance misuse:

• Integrative whole person healthcare - breaking down silos of care
• Destigmatize! Normalize human experiences in response to unhealthy, oppressive, and toxic systems
• Prevention education focusing on the impacts of trauma in and on the body
• Free support services without waitlists - walk-in services that are accessible

Process for Selecting Priority Strategies
Participants in our community input sessions were asked to identify strategies related to the root causes of mental illness and substance misuse in our community. They were provided examples of evidenced-based strategies, as well as prompted to include innnovative ideas and approaches that were no-cost or low-cost approaches. A nominal group dot voting process was used to identify what strategies most resonated across the group. Summary themes and data were shared with the CHIP Leadership team, as well as the CHIP Advisory to make additional recommendations based on feasibility, leverage and impact.

Additional Resources

Evidence Base

Evidence-Based Strategies 

These are actions and approaches that have been shown to make a difference on mental health and substance misuse:

There are six core principles of Trauma-Informed Care (TIC), as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), to inform its work with health and behavioral healthcare systems and organizations:

• Safety
• Trustworthiness and Transparency
•  Peer Support
• Collaboration and Mutuality
• Empowerment, Voice and Choice
• Cultural, Historical, and Gender Issues

SAMHSA. (2014). Concept of Trauma and Guidance for a Trauma-Informed Approach, p10. Pub ID#: SMA14-4884.

What We Do

https://abipa.org/

2022 Progress on CHIP

Asheville-Buncombe Institute for Parity Achievement (ABIPA) has plans to implement a youth mental health program in a predominantly BIPOC housing development. The program will focus on youth outreach and education based on the Mental Health First Aid model and other evidence-based resiliency interventions. With recent program funding, the youth mental health program will be able to expand their ability to reach local BIPOC youth and build opportunities for authentic connection and community building. This pilot program is set to begin in early March and will run through the end of June 2023. The desired long-term outcome is for the program to continue once enhanced funding is secured.

2023 Progress on CHIP

The funding for the suicide prevention programming ended after fiscal year 2023.

What We Do

https://wncll.org/

2022 Progress on CHIP

The WNC Listening Line, a joint project of SeekHealing & Sunrise Community for Recovery and Wellness, has recently received state funding to update and translate the WNC Listening Line training curriculum into Spanish to begin an initiative to expand Spanish-speaking services on the WNC Listening Line. A health educator has already updated the curriculum for cultural relevance and appropriateness and the final stage for translation will begin in March. The WNC Listening Line has trained 234 listeners on learning social health skills related to connection, communication and building healthy relationships. The WNC Listening Line supported 1,256 individuals who called the line over 3,700 times in 2022. Additionally, SeekHealing has continued to design and host multiple community events throughout WNC to support community members with accessing opportunities to authentically connect with others. In 2022, there were 746 individuals who attended 345 community connection events hosted by SeekHealing in Buncombe County.

Unfortunately, the WNC Listening Line's grant funding for operations expired near the end of the year, making it purely volunteer-run. These funding barriers have created significant staffing challenges for covering/answering the listening line consistently. Exploration for ongoing funding is continuing. 

2023 Progress on CHIP

In 2023, Seek Healing provided 2 full-day trainings for counselors, clinicians, peer supports, and other mental health and harm reduction professionals on Motivational interviewing and listening skills.

What We Do

https://www.ifpha.org/

2022 Progress on CHIP

The expanded mental health screening and education series did not start during the last quarter (Oct.-Dec. 2022), as IFPHA was launching new chronic disease prevention initiatives. IFPHA continues to provide mental health screenings for home-bound participants, and in the next quarter there will be more focus on expanding mental health components to collect data on the identified CHIP performance measure.

2023 Progress on CHIP

In fiscal year 2023, The Institute for Preventive Healthcare & Advocacy made the decision to no longer track this measure. IFPHA is continuing their community outreach and has also expanded their efforts by partnering with local churches to provide health education.

What We Do

https://www.buncombecounty.org/governing/depts/hhs/initiatives/closer.aspx

2022 Progress on CHIP

The Buncombe County Community Paramedic (PORT) program provides a Certified Peer Support Specialist to supplement traditional Emergency Services staff for individuals who have overdosed or are experiencing a substance use disorder crisis. Community Paramedicine is focused on substance use disorder support, emergency assistance with food and shelter, and basic medical training like wound support.

FY 2022 (July-June) 359 served, of these 89 intakes/SDOH plans

FY2023 (July through current date) 201 individuals served, of these 69 intakes/SDOH plans

Of those served, 90 Community Paramedicine/PORT participants made first appointment with MAHEC’s OBOT program (an additional 4 entered long term inpatient/residential programs before first appointment with MAHEC’s OBOT program).

The participants who made their first appointment to MAHEC’s OBOT team after MAT dosing from Community Paramedics:  

• 56 remain actively engaged
• 40 of these 56 have remained engaged with MAHEC’s OBOT for at least 1 month
• 35 have graduated to monthly appointments based on consistent negative drug screens and positive progress within their own recovery
• 15 entered Long term inpatient/residential treatment programs
• 17 obtained employment
• 9 entered sober living housing/obtained their own housing

2023 Progress on CHIP

The Post-Overdose Response Team continues to provide services via clinicians, peer support specialists, and paramedics. Funding for a majority of the PORT team changed in 2023, and is currently covered by Opioid Settlement money. As a result of this funding change, some programmatic measures (performance measures) stopped being tracked as grant funding and reporting requirements changed (i.e. missing final data for 2023). 

What We Do

https://www.buncombecounty.org/governing/depts/hhs/initiatives/closer.aspx

2022 Progress on CHIP

Buncombe County HHS developed MOAs with partner harm reduction agencies (WNC AIDS Project/WNCAP, Sunrise Community for Recovery & Wellness, Holler Harm Reduction, and Steady Collective) to utlize Opioid Settlement funding to increase access to Naloxone supplies for enhanced community-wide distribution. Through a collective impact framework all of these agencies work together to assess community needs and emerging issues, collaborate to build and distribute necessary supplies, make structured plans for outreach, and implement community engagement initiatives. All of the MOAs are currently in place and widespread Naloxone distribution is set to begin in Spring 2023. 

2023 Progress on CHIP

As 2023 data reflects, commuity engagement with harm reduction services continues to grow. New initiatives include: NaloxBox (emergency overdose reversal kits) being installed throughout County-owned buildings and within community organizations and local community centers; monthly drop-in community trainings on harm reduction and overdose reversal; expanding installation of needle disposal kiosks in the community and in local parks.

What We Do

https://circleofsecuritynetwork.org/the_circle_of_security.html

2022 Progress on CHIP

Trainings for COSP are now being held regularly for Buncombe County parents, caregivers, and a wide variety of service providers in order to support healthy parent/caregiver-child attachment and attunement. Participants who engage in the 8-week training series complete a survey after the final session to assess their knowledge and behavior change related to understanding the child’s bids for attention and the underlying emotional need, as well as the impact of the adult/caregiver’s childhood and lifetime experiences on interpreting the emotional needs of the child. A process to access county-specific data on the identified CHIP metrics for the COSP program are underway and performance measure updates should occur by June 2023.

2023 Progress on CHIP

COSP trainings have continued throughout 2023 in Buncombe County. In June 2023, longitudinal training outcomes data was compiled and shared for updates in the identified performance measures. The outcomes data was collected from October 2020 through June 2023 from 205 parents/caregivers and 50 early childhood professionals. Early childhood professionals participating in these Circle of Security Parenting groups included: early educators; early intervention staff and service providers, including Children’s Development Service Agency (CDSA) staff working with parents and educators of birth to three-year olds; child welfare professionals; mental health providers; and in-home visitors. Additional Circle of Security Parenting groups have been offered to parents, caregivers, and early childhood professionals in Buncombe County during this period. The numbers reflect only the evaluations collected in a centralized data system and do not include participants in all groups. Efforts continue to increase the number of COSP facilitators using the centralized system.

More information about the Circle of Security Parenting program can be found at the Circle of SecurityInternational website at www.circleofsecurityinternational.com.

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind Campaign Reach.

What's Helping What We Do? These are the positive forces at work in View From Here that influence how much we do or how well we do it.

• Consistent communications related to our priority health topics builds resident trust in public health.
• Hyper-local, tailored, story driven messages resonates with our communities in WNC.
• Social media communications is an effective way to spread health information to even our most rural communities.
• All communities throughout regions 1 and 2 communicating the same messages builds a surround sound effect that builds trust and supports positive behavior change.

What's Hurting What We Do? These are the negative forces at work in View From Here that influence how much we do or how well we do it.

• Our priority health topics can be met with stigmatizing public reactions.
• While this work is incredibly successful, it’s also resource intensive and lack of ongoing funding raises the question of long-term sustainability.
• Because of capacity limitations, we aren’t able to engage all of the community based partners we would like to include.

Alignment

Chronic Disease (Heart Disease & Diabetes) and our related result are aligned with the following Healthy NC 2030 indicator:

• Life expectancy ratio

Experience and Importance

How would we experience this result in our community if we are successful?

• Eliminate the achievement gap
• All kids/all people have access to safe green spaces
• Quality health outcomes
• Seen, heard, and taken care of by healthcare providers
• Access to healthy/fresh food
• Access/attain safe and affordable homes
• Knowledge of and access to services/resources
• Free transportation
• Accountability and commitment
• Dismantle hierarchical systems
• Less gatekeeping services
• Systems that empower
• Self-advocacy to meet needs
• Equitable opportunities

What information led to the selection of Chronic Disease: Heart Disease & Diabetes and this related result?
Heart Disease and Diabetes were one of 5 health conditions based on the size and severity of the issue in our community. Both primary and secondary data sources were compiled to support with size, severity, and feasibility. The Buncombe County CHIP Advisory Council, with representation from 40+ community organizations, were actively engaged in multiple monthly work sessions to identify which community health conditions to prioritize based on relevance, impact and feasibility.
 

Key findings related to Chronic Disease included:

• 6% of respondents consume five or more servings of fruit and vegetables per day compared to 11% from the 2015 Buncombe CHA 
• 23% of survey respondents meet the recommended amount of physical activity compared to the Healthy People 2030 target of 28% or higher 
• 65% of survey respondents have a Body Mass Index (BMI) of 25.0 or higher compared to 59% from 2015 Buncombe CHA 

Chronic Disease – Heart Disease and Diabetes

• Buncombe County’s 2015 – 2019 disaggregated diabetes mortality rates for Black/African American men are nearly 7 times higher than rates for all Whites combined 
• 7% of all Buncombe County survey respondents have been diagnosed with heart disease compared to 5% from the 2018 Buncombe CHA 
• 12% of Black/African Americans Buncombe County survey respondents have experienced a heart attack or have been diagnosed with heart disease compared to 7% of White survey respondents 

Narrative

Chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both (CDC, 2022). SDoH, or root causes, have been found to “serve as a direct cause for a number of diseases” (Cockerham, et al., 2017). According to the National Academy of Medicine, the most significant underlying determinants of health are “income, accumulated wealth, education, occupational characteristics, and social inequality based on race and ethnic group membership” (2017). The Adverse Childhood Experience Study (ACES) and subsequent research expanding the original ACES and Community ACES, known as the Pair of ACEs, connect how stress and trauma increase the risk of chronic illness and premature deaths (CDC, n.d.a.; Social Policy Institute, n.d.)

In utilizing a social-ecological framework and life course approach, Black, Indigenous, and People of Color (BIPOC) groups are often most negatively impacted by chronic disease due to systemic oppression, influences of intergenerational trauma, and individual and community adverse childhood experiences (ACEs and Community ACEs) - meaning that BIPOC individuals experience increased risks for developing chronic diseases such as diabetes and heart disease. There is also a connection between food security, poverty, and chronic disease, as barriers to accessing prevention services, as well as timely health and wellness resources often creates further health inequity (Jayathilaka, 2020). When these circumstances are paired with existing issues related to high cost of living, lack of living wages, and chronic housing insecurity in Buncombe County, the negative impact on health outcomes is amplified.

Centers for Disease Control and Prevention. (2022, May 3). About chronic disease. Available from https://www.cdc.gov/chronicdisease/about/index.htm

Center for Disease Control. (n.d.a.). Adverse Childhood Experiences. Available from: https://www.cdc.gov/violenceprevention/aces/

Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The social determinants of chronic disease. American journal of preventive medicine, 52(1S1), S5–S12. https://doi.org/10.1016/j.amepre.2016.09.010 

Jayathilaka, R., Joachim, S., Mallikarachchi, V., Perera, N., & Ranawaka, D. (2020). Do chronic illnesses and poverty go hand in hand? PloS one, 15(10), e0241232. https://doi.org/10.1371/journal.pone.0241232

Magnan, S. (2017). Social Determinants of Health 101 for Health Care: Five Plus Five. National Academy of Medicine. https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/

Social Policy Institute. (n.d.). The pair of ACES: Knowledge to action brief. San Diego State University School of Social Work. Available from https://cblcc.acf.hhs.gov/wp-content/uploads/The-Pair-of-ACEs-K2A_4.2.2021.pdf#:~:text=Children%20and%20adults%20who%20have%20had%20adverse%20childhood,the%20Pair%20of%20Aces%20%28Ellis%20%26%20Dietz%2C%202017%29.

Partners

Partners With A Role to Play

• CHIP Advisory Council members and organizations
• North Carolina Department of Health & Human Services - Healthy Communities funding
• WNC Healthy Impact
• YMCA of Western North Carolina - Asheville
• YWCA-Asheville
• Buncombe County Communications and Public Engagement (CAPE)
• *neighborhood/community gardens & food banks
• UNETE
• CIMA

Actions and Accomplishments

Process for Selecting Priority Program/ Strategies

The overall approach used was a modified Results-Based Accountability process. A community input process was facilitated using the RBA Whole Distance Exercise framework with multiple events held in partnership with community providers to listen to community voices. These input sessions included over 75 individuals including those with lived experience, health care providers, social service agencies, advocacy organizations and local non-profits. The professionals participating included those working in the health field as well as those working to address many of the social and economic factors that impact health.

The following actions have been identified by our CHIP Advisory and Leadership Team and community members as ideas for what can work for our community to make a difference on chronic disease:

Actions and Approaches Identified by Our Partners 

These are actions and approaches that our partners think can make a difference:

• One-stop whole-person health services
• Community Health Workers
• Prevention Education
• Cyclical Outreach - bringing services to the community on a rotation
• Dismantling white supremacy culture within organizations and systems that provide healthcare
• Addressing provider bias to include policies and practices that uphold racism within healthcare 
• Increase healthcare models that include home-based services - the ability to bring healthcare to individuals who are most in need
• Tailored outreach to commuinities who have experienced discrimination and/or a feel a lack of safety within healthcare institutions
• Transportation solutions that allow for all residents to access healthcare services (expand bus routes and frequency of routes)

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference:

• Minority Diabetes Prevention Program (MDPP) via YMCA
• Community Health Workers model, particularly for populations facing lanugage injustice
• Culturally appropriate fresh food and produce market options
• Enhanced EBT/SNAP benefits for purhcase of fresh fruits and vegetables

What Community Members Most Affected by Chronic Disease (Heart Disease and Diabetes) Say 

These are the actions and approaches recommended by members of our community who are most affected by chronic disease conditions:

• Easy, accessible and afforable pre-packaged healthy food options - make choosing healthy options easier vs. fast food
• Whole-person care; integrating services into a "one stop shop" or bringing services to the people
• Addressing provider bias and stigma - all people should feel heard, supported, and safe when accessing health services

Additional Resources

Evidence Base

Evidence-Based Strategies 

These are actions and approaches that have been shown to make a difference:

Healthy People 2030 Evidence-Based Practices: "Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers"

Interventions that engage community health workers to prevent cardiovascular disease (CVD) among clients at increased risk.

• Engage community health workers in a team-based care model to improve blood pressure and cholesterol.
• Engage community health workers for health education, and as outreach, enrollment, and information agents to increase self-reported health behaviors (physical activity, healthful eating habits, and smoking cessation) in clients at increased risk for heart disease (cardiovascular disease).

Minority Diabetes Prevention Program (MDPP) is an evidence-based model for engaging BIPOC individuals at risk of developing Type 2 diabetes.  MDPP participants focus on incremental and measured lifestyle changes with the guidance and support of a CDC-certified coach. The goal is to achieve 5 to 7 percent weight loss by the end of the program through healthy eating and physical activity. Classes cover a variety of health and wellness topics, including meal planning, tips for eating healthy away from home, and ways to increase daily activity.

U.S. Department of Health and Human Services. (2015). Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke/evidence-based-resources

North Carolina Department of Health and Human Services. (2020). Evidence-Based Diabetes Prevention Program to Eliminate Health Disparities.https://files.nc.gov/ncdhhs/SL-2017-57--Section-11E.5.-b--Minority-Health---Diabetes-Prevention-Program-2020--Final-.pdf

What We Do

https://www.buncombecounty.org/governing/depts/community-engagement/default.aspx#sec-markets-connectors

2022 Progress on CHIP

The Buncombe County’s CAPE Team partners with multiple community agencies and MANNA Food Bank to provide free monthly fresh food pop-up markets in various areas of Buncombe County as a way to support residents with access to healthy foods. These markets occur regularly in designated communities and often include other agencies that provide health and wellness related services to support with access and outreach.

2023 Progress on CHIP

The CAPE Team continues to provide free fresh foods throughout the Buncombe County region, in 2023 CAPE increased their reach by expanding their Community Pop-Up Markets to include a location in the Fairview community.

What We Do

https://www.ifpha.org/

2022 Progress on CHIP

The Institute for Preventive Healthcare and Advocacy has expanded programming to include outreach and education events at several local BIPOC churches to support with healthy eating, diabetes prevention, and chronic disease screening.

October – December 2022: IFPHA was able to connect with 71 BIPOC residents of Buncombe County through new church outreach and education events. IFPHA partnered with a local community health worker organization, UNETE, to outreach 84 community health workers and provided training and education on diabetes and heart disease prevention. IFPHA provided their monthly lunch and learn series on healthy eating and diabetes prevention for 11 BIPOC Buncombe residents and linked 67 home-bound Buncombe County residents to primary care provider services for ongoing prevention and screening.

2023 Progress on CHIP

IFPHA continued to provide outreach and engagement events throughout 2023 for the Shiloh Community. Lunch and Learn participant data from 2023 reflects ongoing increases in knowledge and access to healthy foods. Learning sessions covered healthy eating/recipes, as well as stress management, prevention monitoring for chronic illness, community outings, and access to community resources through guest speakers. 

Partners

Partners With A Role to Play

• North Carolina Department of Health & Human Services: Healthy Communities funding 
• CHIP Advisory Council members and organizations

• * To be further defined - this is still in planning phases

Actions and Accomplishments

Process for Selecting Priority Program/ Strategies

The overall approach used was a modified Results-Based Accountability process. A community input process was facilitated using the RBA Whole Distance Exercise framework with multiple events held in partnership with community providers to listen to community voices. These input sessions included over 75 individuals including those with lived experience, health care providers, social service agencies, advocacy organizations and local non-profits. The professionals participating included those working in the health field as well as those working to address many of the social and economic factors that impact health.

The following actions have been identified by our CHIP Advisory and Leadership team and community members as ideas for what can work for our community to make a difference on chronic disease.

Actions and Approaches Identified by Our Partners 

These are actions and approaches that our partners think can make a difference:

• Gentrification, systemic racism/land taken (eliminating places to exercise and be outside safely)
• Lifestyle education – process for making changes in behaviors
• "There are not enough greenways, bike lanes, sidewalks, dense development. We are still reliant on the car. People need to move more and the attachment to our long-held values of cars, busy streets that are unsafe for walking/biking. We need a community design that is people centric." 
• "Lack of greenways and other physical activity outlets in rural areas of the County."

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference:

• Community Health Workers - linking to resources and eduction on healthy activities and movement
• Expansion of bicycle lanes and sidewalks (in some locations in the County)

What Community Members Most Affected by Chronic Disease (Heart Disease and Diabetes) Say 

These are the actions and approaches recommended by members of our community who are most affected by chronic disease conditions:

• Make public transportation accessible for ALL Buncombe County residents (particularly those who experience mobility issues with walking)
• Increasing access to healthcare advocates (community health workers) for better systems navigation and support with healthy activities and movement

Additional Resources

Evidence Base

Evidence-Based Strategies 

These are actions and approaches that have been shown to make a difference:

Studies have found that individuals living in less walkable neighborhoods have a higher risk for developing heart disease, high cholesterol, high blood pressure, and diabetes compared to indivuduals living in walkable neighborhoods.

Association Between Neighborhood Walkability and Predicted 10‐Year Cardiovascular Disease Risk: The CANHEART (Cardiovascular Health in Ambulatory Care Research Team) Cohort. Nicholas A. Howell, Jack V. Tu, Rahim Moineddin, Anna Chu and Gillian L. Booth Originally published31 Oct 2019https://doi.org/10.1161/JAHA.119.013146Journal of the American Heart Association. 2019;8:e013146

Walking (frequency and duration) is not only affected by objective elements, but also by the subjective quality of an area, and perceived suitability and ease for walking. In addition, aspects such as perceived safety and the atmosphere of an area may also have great influence on walking.

Jonas De Vos, Katrin Lättman, Anna-Lena van der Vlugt, Janina Welsch & Noriko Otsuka (2022) Determinants and effects of perceived walkability: a literature review, conceptual model and research agenda, Transport Reviews, DOI: 10.1080/01441647.2022.2101072

What We Do

https://abipa.org/

2022 Progress on CHIP

ABIPA (Asheville Buncombe Institute for Parity Achievement) will be conducting walkability assessments within communities to assess potential barriers or improvements to enhance pedestrian safety. ABIPA will be using a community participatory research framework to recruit local community members to assist with conducting assessment. The assessments will be completed by Spring 2023.

2023 Progress on CHIP

ABIPA completed 4 Walkability Assessments within a public housing community and the Shiloh Community, a historically Black neighborhood within Asheville. The funding for this project ended after FY 2022.

Partners

Partners With A Role to Play

• CHIP Advisory Council members and agencies
• YMCA of Western North Carolina - Asheville
• YWCA - Asheville
• Buncombe County Communications and Public Engagement (CAPE) Team
• *neighborhood/community gardens & food banks
• UNETE
• CIMA
• Asheville Buncombe Institute for Parity Achievement (ABIPA)
• Institute for Preventive Healthcare & Advocacy
• Buncombe County Age Friendly services
• Buncombe County Adult & Aging services

Actions and Accomplishments

The overall approach used was a modified Results-Based Accountability process. A community input process was facilitated using the RBA Whole
Distance Exercise framework with multiple events held in partnership with community providers to listen to community voices. These input sessions included over 75 individuals including those with lived experience, health care providers, social service agencies, advocacy
organizations and local non-profits. The professionals participating included those working in the health field as well as those
working to address many of the social and economic factors that impact health.

The following actions have been identified by our CHIP Advisory and Leadership Team and community members as ideas for what can work for our community to make a difference on mental health and substance misuse in Buncombe County.

These are actions and approaches that our community partners and Buncombe County residents, including those directly affected by Chronic Disease, say it would take to do better:

These are actions and approaches that our partners think can make a difference:

• Community gardens
• BIPOC Food sovereignty 

What is Currently Working in Our Community 

These are actions and approaches that are currently in place in our community to make a difference on chronic disease:

• Home visiting programs - bringing services to the people
• Food preparation and cooking classes to reduce chronic health conditions
• Community Health Workers
• YMCA's diabetes programming

What Community Members Most Affected by Chronic Disease (Heart Disease & Diabetes) Say 

These are the actions and approaches recommended by members of our community who are most affected by chronic disease:

• Integrative whole person healthcare - one stop shop for health
• Food soverienty initiatives - restoring green spaces to historic BIPOC communities 
• Increasing easy/conveient access to healthy food options
• Knowing about risk factors, how to facilitate conversations across generations about cultural practices that impact and reduce risk

Process for Selecting Priority Strategies
Participants in our community input sessions were asked to identify strategies related to the root causes of chronic disease in our community. They were provided examples of evidenced-based strategies, as well as prompted to include innnovative ideas and approaches that were no-cost or low-cost approaches. A nominal group dot voting process was used to identify what strategies most resonated across the group. Summary themes and data were shared with the CHIP Leadership team, as well as the CHIP Advisory to make additional recommendations based on feasibility, leverage and impact.

Additional Resources

Evidence Base

Evidence-Based Strategies 

These are actions and approaches that have been shown to make a difference on mental health and substance misuse:

What We Do

https://ymcawnc.org/minority-diabetes-prevention-program-mdpp

2022 Progress on CHIP

The Minority Diabetes Prevention Program is a lifestyle management program provided by the YMCA that is designed to support participants in preventing the onset of Diabetes Type II.  Delivered by the YMCA of WNC, the program emphasizes intentional relationship building, connectedness among participants and excellent program facilitation by skilled Lifestyle Coaches.   For 2022, 71 people enrolled in MDPP with an 87% retention rate over the 12-month, 24 session program geared toward serving priority populations including Hispanic/Latino and Black/African American. The majority of MDPP’s programs were delivered virtually with two in-person Spanish Speaking programs.  In addition, their staff screened over 150 community members for prediabetes.

Testimonial from Lifestyle Coach, Rosario Villarreal about her Summer 2022 program cohort:

 ‘Our greatest success has been staying together despite the circumstances.’

Multiple cases of COVID, flu, 3 deaths of relatives of the participants, gallbladder operation, pre-heart attack, accident at work, etc. affected our class.

Over the last two to three years cases like these have been seen in the groups and the number of people who leave the program has increased due to these circumstances, it is more important than ever to create community through in-person classes with the option to participate virtually.

Referring participants to additional resources has become part of the daily work of supporting the participants not only for them but in asking for support for their families or friends. In this particular group (8 participants) referrals were made to the Mexican Consulate for power of attorney procedures, funeral services, mental health, food resources, help with emergency Medicaid, etc. In other classes we help participants to find jobs.

Equity is:  Relieving participants' stress with the extra support provided, which is crucial for blood sugar levels to drop or at least maintain prediabetes levels.

2023 Progress on CHIP

YMCA of WNC continues to provide Minority Diabetes Prevention classes in both Buncombe and Henderson counties. Due to the hard work and dedication of the YMCA staff, the MDPP program earned the CDC Full Recognition status. With the change in status, the MDPP program can now receive Medicare reimbursement for services. The YMCA also began offering DPP, Diabetes Prevention Program earlier this year.

What Is It?

The Buncombe County Tobacco Action Study Committee (TASC) was named by the HHS Board to lead a community engagement and evaluation process for Buncombe County’s tobacco policy. In the County’s original tobacco use ordinance, combustible tobacco/cigarettes were specifically prohibited, and in 2022 the County’s tobacco policy was updated to include prohibition of e-cigarettes and vaping on County properties. The primary concerns that the TASC Community Engagement group identified for evaluation were related to the equitable enforcement of the policy and defining equitable consequences for ordinance violation.

2022 Progress on CHIP

In 2022, TASC Community Engagement partnered with Buncombe HHS CAPE Team to broadly promote community awareness about the latest ordinance change, including installment of new signage in County parks. At the end of 2022, a community input survey was developed with TASC Community Engagement and HHS CAPE Team for online public engagement to determine: equitable tobacco ordinance enforcement, assess cultural humbleness and accessibility of local tobacco cessation resources, and to identify ongoing community needs and concerns related to tobacco use in Buncombe County. The TASC public input survey will go live in early 2023 for community engagement, and a similar version of the survey will run internally for all Buncombe County employees to access. Once both survey projects are finished the TASC Community Engagement and HHS CAPE Teams will produce formal equity recommendations for the HHS Board to consider for future Buncombe County tobacco ordinance/policy updates.   

2023 Progress on CHIP

The TASC community engagement survey was launched in 2023 to gather public input on smoking and tobacco restrictions, enforcement, and access to cessation supports. As data reflects, there was a wide level of engagement from community which provided feedback around the current tobacco ordinance. Compiled data with qualitative response themes were shared with the Health and Human Services board, as well as senior leadership. Data and feedack collected from this survey will continue to influence and support any future changes to the current tobacco use ordinace for Buncombe County. 

What We Do

https://www.ifpha.org/

2022 Progress on CHIP

The Institute for Preventive Healthcare and Advocacy has expanded programming to include outreach and education events at several local BIPOC churches to support with healthy eating, diabetes prevention, and chronic disease screening.

October – December 2022: IFPHA was able to connect with 71 BIPOC residents of Buncombe County through new church outreach and education events. IFPHA partnered with a local community health worker organization, UNETE, to outreach 84 community health workers and provided training and education on diabetes and heart disease prevention. IFPHA provided their monthly lunch and learn series on healthy eating and diabetes prevention for 11 BIPOC Buncombe residents and linked 67 home-bound Buncombe County residents to primary care provider services for ongoing prevention and screening. IFPHA is partnering with the UNC-Asheville Health and Wellness department for support with developing and implementing a process for collecting 'better off' data for CHIP performance measures - it is anticipated that these data points will be collected and available in March 2023.

2023 Progress on CHIP

In 2023, IFPHA's focus was on outreach to historic Black neighborhoods and churchs in Buncombe County. Three local churches engaged with programming in 2023, allowing IFPHA to provide regular education and learning sessions, vital monitoring for early detection of chronic disease, and group activities related to health equity. As 2023 data reflects, IFPHA's programming has continued to reach and effectively engage community in learning about a variety of health topics, including the connections between stress and health outcomes, and methods for improving health related to food/diet, exercise/movement, and connection/social supports. 

What We Do

https://www.buncombecounty.org/governing/depts/health/Bcccp.aspx#:~:text=WISEWOMAN%20is%20a%20program%20aimed,250%2D6006%20for%20an%20appointment.

2022 Progress on CHIP

January - December 2022

• WISEWOMAN provided free screenings to 582 uninsured Buncombe County women ages 40-64 in 2022
• 284 participants had one or more elevated blood pressure reading. Blood pressure >120/80
• 258 participants had elevated total cholesterol labs. Total cholesterol > 200
• 217 participants had elevated A1c labs. A1c > 5.6
• 71 participants had elevated fasting blood sugar labs. Blood glucose > 100
• 142 participant reported having diagnosed hypertension.
• 101 participants reported having diagnosed elevated cholesterol.
• 93 participants reported having diagnosed diabetes.

2023 Progress on CHIP

In 2023, the Buncombe County WISEWOMAN Program provided both cardiovascular and Diabetes screenings and healthy behavior follow-up services.

Progress on CHIPs

See links below for 2022 CHIP Updates on Cross-cutting Results:

All people living in Buncombe County, especially our BIPOC communities, access opportunities for whole-person health and wellness and experience equity in all places and systems.

All health, faith-based, social, justice, and educational systems are aware of the impact of trauma on our bodies, brains and behaviors and support our protection and resilience.

See links below for 2022 CHIP Updates on Programs and Performance Measures:

Health Focus Area: Birth Outcomes & Infant Mortality

 A Project NAF A

 A WIC

 A YWCA Mother Love Program

 A Buncombe County Partnership for Children

 A Nurse-Family Partnership

 A Circle of Security Parenting

 A Sistas Caring 4 Sistas (SC4S)

Health Focus Area: Mental Health & Substance Misuse

 A Asheville-Buncombe Institute for Parity Achievement

 A WNC Listening Line

 A Institute for Preventive Healthcare & Advocacy

 A Post Overdose Response Team

 A Harm Reduction/Syringe Exchange partner organizations

 A PACES Collaborative

 A Circle of Security Parenting

Health Focus Area: Chronic Illness (Heart Disease & Diabetes)

 A Buncombe County CAPE Fresh Food/Market Pop-ups

       Institute for Preventive Healthcare & Advocacy Lunch & LearnA

A Asheville-Buncombe Institute for Parity Achievement

 A Minority Diabetes Prevention Program

 A Institute for Preventive Healthcare & Advocacy Community Health Workers

 A Buncombe County Tobacco Action Study Committee (TASC) A

 A WISEWOMAN

 A

Morbidity and Mortality Changes Since Last CHA

NOTE: There have not been any new data releases from the NC State Center for Health Statistics on morbidity and mortality data since the 2021 Community Health Assessment. 

Buncombe County COVID-19 Data

In Buncombe County there have been a total of 69,935 COVID-19 cases to date, and in 2022, there were 27,543 (*see also by group)

In Buncombe County there have been a total of 689 COVID-19 deaths to date, and in 2022, there were 206 COVID-19 deaths.

Leading Causes of Death - Buncombe County, NC *data updated Dec. 2022                                                                                                                           

Robert Wood Johnson 2022 County Health Rankings - Buncombe County, NC 

In 2022, Buncombe County ranked 19 out of 100 NC counties for healthiest outcomes (length of life and quality of life) and health factors (things that can be modified to improve length and quality of life). 

North Carolina's Opioid and Substance Use Action Plan Dashboard - Buncombe County, NC *2022 data is not available yet

Emerging Issues Since Last CHA

• Food Security

In 2022, many Buncombe County residents were dealing with the economic strain caused by inflation and the increasing cost of living. According to the U.S Bureau of Labor Statistics, the cost of food had increased by 12.2% as of the end of June.  As a result of food prices steadily increasing the demand for food assistance also grew. Manna Food Bank reported that in the month of February alone they had served over 100,000 people. Prior to the Pandemic, Manna served this high volume of people over the course of a year. While trying to accommodate the increased need, Manna was also dealing with supply chain shortages as it became difficult to source food. As a result, Manna hosted a virtual fresh food drive, which was specifically raising money that would be used to purchasing food. With no end in sight for inflation easing up, Manna is committed to helping to serve residents despite obstacles.

• Long COVID-19

According to UNC School of Medicine, between 10-30% of people who contracted COVID-19 will experience long-term symptoms as part of a condition known as Long COVID. Symptoms vary for each person and can even at times go away and come back. Generally, symptoms of long-COVID consists of tiredness/fatigue, fevers, shortness of breath, brain fog, joint or muscle pain. Also, people who are experiencing Long COVID could potentially experience new health conditions due to experiencing “multi-organ effects or autoimmune conditions” which could result in developing health conditions such as diabetes, blood clots, or heart conditions. According to the Center for Disease Control, by November 2022 15% of North Carolinians had experienced Long COVID. Currently, researchers are trying to understand if some people may be more at risk for developing Long COVID

• Youth Mental Health & Suicide

The 2021 Adolescent Behaviors and Experiences Survey (ABES) was completed by a nationally representative sample of high school youth January – June 2021 and compiled into a thematic report. Findings from the ABES demonstrate that adolescents in the United States are experiencing a mental health crisis, they have experienced a wide range of trauma, and there are ongoing experiences of racism in school/education settings.  

According to the CDC's ABES study, nationally:

• In 2021, 12% of female students, more than 25% of LGBTQ students, and 17% of other or questioning students attempted suicide during the past year compared to 5% of their male peers and 5% of their heterosexual peers
• More than half of students experienced emotional abuse in the home and more than 10% reported physical abuse in the home.
• Lesbian, gay, and bisexual students were far more likely to report physical abuse, with 20% reporting that they had been physically abused by a parent or other adult in their home, compared to 10% of heterosexual students.
• Black students were most likely to report hunger, with nearly a third reporting that there was not enough food in their home during the pandemic.
• More than one third of all U.S. high school students felt they had been treated badly or unfairly at school because of their race or ethnicity.
• Asian, Black, and Multiracial students reported the highest levels of experiencing racism.
• Students who reported racism were also more likely to experience poor mental health and less likely to feel connected to people at school.

At the Buncombe County level, in 2022 there were 351 ER visits for suicide ideation and 141 ER visits for suicide attempts and/or self-harm for youth in Buncombe County, and when the data is combined with the last six years, it is evident that youth suicidal ideation and self-harm numbers continue to increase. As a state, North Carolina ranks in 42 out of all U.S. states for overall child mental health, meaning that youth in North Carolina have a higher prevalence for experiencing mental health distress and a low rate of accessing mental health treatment. Data from 2022 reflects that roughly half of North Carolina youth experiencing a major depressive episode did not receive treatment, a trend that spans data across the United States.

• School Mental Health

According to Kaiser Family Foundation, large numbers of public school staff across the United States are repeatedly identifying a decrease in the social and emotional health of K-12 students due to isolation and other mental health impacts from the ongoing COVID-19 pandemic. Kaiser Family Foundation notes that these increased behavioral demands from children are showing up rampantly in classrooms and schools, many of which are already facing teacher and mental health provider shortages due to low pay and burnout.  A portion of federal funding in 2022 (via Bipartisan Safer Communities Act and American Rescue Plan Act) was designated specifically for national funding for early childhood and secondary education to improve access to school-based mental health and health care services.

At a local level, 2021-2022 public school data (Buncombe County Schools and Asheville City Schools) and charter school data reflects high rates of chronic absenteeism that have continued since the emergence of COVID-19 during the 2020-2021 school year. School Superintendents from Buncombe County and Asheville City have identified an increase in student behavioral challenges and relate this increase to the impacts from the COVID-19 pandemic (missing the consistent structure of school, missing academic instruction, and gaps in social skills and brain development), as well as the impacts of poverty and economic challenges for families. During 2021-2022, roughly 20% of charter school students, 28% of Asheville City School students, and 28% of Buncombe County School students missed 10% or more of total academic instruction during the 2021-2022 school year due to absences. There also remains clear learning and achievement disparities when 2021-2022 public school data is disaggregated by race and ethnicity, with Black/African American students facing higher rates for discipline, school consequences, and referrals to law enforcement when compared to their White peers.

• Asheville City Schools (ACS) has created ‘reset rooms’ on all elementary and middle school campuses to further support students with learning and practicing emotional regulation skills with trained professionals, and all ACS campuses have school-based mental health professionals on-site to support students experiencing distress (13 mental health professionals in total). ACS also plans to dedicate additional funding in the upcoming school year to continue to support student mental health.
• Buncombe County Schools (BCS) has invested resources and training for teachers and school administrators on internal and external bias and behavioral communication which have continued into the 2022-2023 school year. Additionally, BCS has been working to update the “Student Code of Conduct” to include new, alternative options to address student behaviors in order to avoid use of suspensions and referral to law enforcement/juvenile justice, as BCS teachers and administrators understand that a student’s behavior serves as a form of communication about what is missing or needed in a given moment. One notable increase in BCS student suspensions and law enforcement referrals in the last school year was related to students vaping on school property (tobacco and marijuana), which connects back to mental health and substance misuse as areas where students need additional supports. BCS has partnered with United Way to assess disaggregated school data around four themes that center equity as a means to expand services and interventions to better support students in schools, and BCS also continues to expand services and designated classrooms for students who do not speak English or for students who are multi-lingual.

Additionally, 48% of Buncombe County School students, 32% of Asheville City School students, and 31% charter school students were economically disadvantaged in the 2021-2022 school year, meaning they qualify for the National School Lunch program, SNAP benefits, other economic support services, etc. On a broader level, combining this data suggests that students locally are also experiencing mental health challenges related to their experiences with traumatic stress (interpersonally and systemically) and familial barriers to accessing social determinants of health such as safe housing and food security.

• mpox

In May 2022, cases of mpox (previously known as monkeypox) began being reported internationally, and by June 2022, North Carolina saw the first case. According to the World Health Organization, 2022 was the first time “Mpox cases and clusters have been reported concurrently in non-endemic and endemic countries in widely disparate geographical areas.” Many of the mpox cases were  identified through sexual health services, however, mpox is also known to be transmitted to humans through close contact with an infected person, including contact with lesions, body fluids, respiratory droplets, as well as contaminated materials such as clothing or bedding. Vaccines that were once developed for smallpox have been found to be dually effective for mpox; as a result, interventions for testing and distribution of those vaccines locally, state-wide, and nationally targeted groups most at risk for transmission. To date in North Carolina there have been 707 diagnosed cases of mpox, and in 2022 there were 12 cases of mpox diagnosed in Buncombe County.

• Community Health Worker Funding

In response to the COVID-19, North Carolina Departments of Health and Human Services (NCDHHS) allocated funding to support the work of Community Health Workers (CHWs). CHWs were paramount in the State's efforts of addressing the pandemic, as they played "an important role in providing education and support to increase vaccination rates across the state, particularly as we address rising COVID-19 cases." In 2021, UNETE a local non-profit organization was awarded funds to hire, train and manage CHWs who served Buncombe, Henderson, and Transylvania counties. In Buncombe County there were a total of 83 CHWs who were providing services to the community. This funding has since ended and as a result it is estimated that 50-75 CHWs in the WNC region experienced job loss.

New/Paused/Discontinued Initiatives Since Last CHA

New Initiatives

• CHIP One-Question Campaign

As part of our outreach to the community for their input, Buncombe County conducted a one-question campaign to better understand the needs of our community. In partnership with Buncombe HHS Communications Team and Buncombe County CAPE Team residents were surveyed to collect information on the most important thing residents needed for their health and well-being. Residents were surveyed during community pop-markets and community events. Residents were also able to provide their responses via Buncombe County’s Public Input website and by filling out paper responses located at the health department. 

• Buncombe County Health & Human Services Mobile Unit

The Buncombe County Public Health Mobile Team launched in July 2022, and they have distributed over 1,500 vaccines at more than 80 events across Buncombe County. This team was also an essential part of the COVID-19 and Mpox response efforts, as well as surge capacity for Immunization Clinics. The Mobile Team is focused on providing services to historically marginalized populations, low-income areas and rural communities. The goal of the new unit is to help make public health services more equitable and accessible to more Buncombe residents, especially those who may not have transportation, may have limited or no access to health providers, feel unsafe or anxious about seeking care, or those who, for any other reason, face barriers receiving essential public health services. Currently, the BC PHMT provides the following services: vaccinations, sexually transmitted infections (STI) treatment, vaccination reviews, and health education. In early 2023 the mobile team will be partnering with Buncombe County’s Syringe Service Program (SSP) to pilot Rapid HIV/Hepatitis C testing on-site for SSP participants.

• Partnership for Children - Building Capacity in Buncombe County to Expand NC Pre-K Availability & Accessibility

During the 2022/2023 school year, Buncombe Partnership for Children (BPFC) began implementing a multi-year initiative to increase Buncombe County children’s access to NC Pre-K through a variety of identified provider, classroom, and family strategies. Funding for this initiative came from the American Rescue Plan Act (ARPA) and will support Buncombe County’s Strategic Plan focus area, an educated and capable community with specific focus on increasing kindergarten readiness. Some of the new initiative’s strategies include, training and licensure supports for early childhood providers, providing classroom implementation support for the NC Pre-K curriculum, and supporting pay parity between NC Pre-K and NC K-12 teaching positions. The initiative will also increase strategic planning for implementing solutions to barriers to access, such as transportation, applications, and cost of enrollment per child. Through increasing provider licensure capabilities and familial/child access to NC Pre-K programming, BPFC is working to enhance all children’s social and emotional readiness for entry into Kindergarten.

• WNC Women's Health Fair

A multi-county initiative is currently in the works through a partnership with the National Institute of Environmental Health Sciences to host a Women’s Health Awareness Conference. The Women’s Health Awareness (WHA) is an initiative within the National Institute of Environmental Health Sciences (NIEHS) Clinical Research Branch (CRB), Office of Human Research and Community Engagement (OHRCE) that:

• Provides evidence-based community interventions to promote wellness, environmental health literacy, and environmental public health
• Increases community health resiliency
• Advances health equity by improving health care access and quality

In Spring 2023, women across Western North Carolina will come together in Waynesville, NC to partake in health education sessions, and health screenings including mammograms and dental services.

• Handle With Care Initiative

Asheville City Schools and Buncombe County Schools have partnered with Buncombe County Emergency Medical Services (EMS), Buncombe County Sherriff’s Office, Asheville Police Department, and Asheville Fire & Rescue to create a communication system to enhance trauma-informed practices while better supporting students who have been exposed to trauma. The initiative created a phone line that allows emergency responders to directly call and connect with school administrators to notify them when a student or students have been exposed to a traumatic event outside of school. The notification then allows school administrators, counselors, and teachers/faculty to be prepared to receive the identified student(s) with additional supports and services upon their arrival at school.

• School Health Clinics

In the Spring of 2022, a new School-Based Health Center was launched at Asheville Middle School with a second opening later in the year at Erwin Middle School. The school-based health center project came out of a partnership amongst Asheville City Schools, Buncombe County Schools, Mountain Area Health Education Center (MAHEC), Buncombe County Health and Human Services, and United Way of Asheville and Buncombe County, with funding support from the US Department of Education, the Dogwood Health Trust, and local donors. The group chose Blue Ridge Health (BRH) as the primary medical provider for the two new school-based health centers in Buncombe County, given BRH’s experience providing school-based health clinics in multiple other NC counties. The new school-based health center, which is located on the Asheville Middle School campus, serves as a fully functioning health clinic with ability to provide physical, mental, and behavioral services. The health center is staffed by a registered nurse, who can diagnose, treat, and screen for a variety of health conditions (including dental, vision, and hearing). The school-based health centers utilize a model that focuses on prevention and early intervention and services can be accessed by students, school staff/faculty, and student’s families.

Paused Initiatives

• Mothering Asheville

By 2027, Mothering Asheville aims to eliminate disparities in infant mortality in Buncombe County, changing the current data indicating that Black/African American babies die at two times the rate of White babies. Mothering Asheville is a cross-sector collaboration working to ensure that more Black babies are delivered on time, at a healthy weight, and survive their first year. Mothering Asheville works with partners to build community capacity, create clinical shifts, communicate strategically, and advocate for institutional policies that address structural racism, implicit bias, access to care, economic and other social factors that influence health. The local inequities in birth outcomes and associated social determinants of health reveal the need for clinical-community collaborations to support pregnant Black women, their babies, and people of color through their lifespans. Mothering Asheville was established as a response to this critical need, bringing together clinical providers, community resident groups, nonprofits, advocacy agencies and others committed to fostering health equity.

The Mothering Asheville group has been on a temporary pause for part of 2022 due to staffing changes within some of the lead organizations. The goal is for Mothering Asheville to begin reconvening in 2023.

• Home Visitors Collaborative

The Buncombe County Home Visitors Collaborative has been on a temporary pause for part of 2022 due to staffing changes within two of the lead organizations (Buncombe County Nurse-Family Partnership, YWCA). Once those leadership positions are hired and filled, the Home Visitors Collaborative will reconvene to begin strategic planning for 2023.

Discontinued Initiatives 

• Trinity Place Youth Shelter

Trinity Place in Asheville, NC, a shelter serving runaway and houseless youth throughout Western North Carolina, closed its doors in May 2022 after ongoing issues with staffing shortages that began with the emergence of COVID-19. The agency providing Trinity’s services, Caring for Children, and parent company, Eckerd Concepts, were forced to make the difficult decision in early 2022. Trinity Place shelter opened in 1992 and supported more than 4,500 youth and families during its 30 years of operation. The physical location for the shelter is owned by Trinity Episcopal Church and a search is currently underway to locate a new provider with capability of running similar shelter support services for youth and families.

Progress on CHIPs

See links below for 2023 CHIP Updates on Cross-Cutting Strategies, Programs, and Performance Measures:

Cross Cutting Result: All people living in Buncombe County, especially our BIPOC communities, access opportunities for whole-person health and wellness and experience equity in all places and systems.

Cross Cutting Result: All health, faith-based, social, justice, and educational systems are aware of the impact of trauma on our bodies, brains and behaviors and support our protection and resilience.

Health Focus Area: Birth Outcomes & Infant Mortality

  WIC

  YWCA Mother Love Program

  Buncombe County Partnership for Children

  Nurse-Family Partnership

  Circle of Security Parenting

Health Focus Area: Mental Health & Substance Misuse

  Asheville-Buncombe Institute for Parity Achievement

  WNC Listening Line

  Institute for Preventive Healthcare & Advocacy

  Post Overdose Response Team

  Harm Reduction/Syringe Exchange partner organizations

  Circle of Security Parenting

  View From Here campaign

Health Focus Area: Chronic Illness (Heart Disease & Diabetes)

  Buncombe County CAPE Fresh Food/Market Pop-ups

  Institute for Preventive Healthcare & Advocacy Lunch & Learn

 Asheville-Buncombe Institute for Parity Achievement

  Minority Diabetes Prevention Program

  Institute for Preventive Healthcare & Advocacy Community Health Workers

  Buncombe County Tobacco Action Study Committee (TASC) 

  WISEWOMAN

Morbidity and Mortality Changes Since Last CHA

Morbidity & Mortality Changes Since Last CHA:

NOTE: There have not been any new data releases from the NC State Center for Health Statistics on morbidity and mortality data since the 2021 Community Health Assessment.

Leading Causes of Death- Buncombe County * data updated September 2023

Robert Wood Johnson 2023 County Health Rankings- Buncombe County, NC

In 2023, Buncombe County's health ranking fell to 21 out of 100 NC counties for healthiest outcomes including quality and length of life and other health factors. For Buncombe County, health factors that could improve the quality of life for residents include addressing adult smoking, obesity, and the number of uninsured residents.

North Carolina’s Opioid and Substance Use Action Plan Dashboard- Buncombe County, NC

As of 2023, Buncombe County had a total of 520 emergency room visits related to overdose. Buncombe County had a higher rate (199.1 per 100,000) of residents visiting the emergency room due to overdose in comparison to the State (161.4 per 100,000 residents).

*2023 Overdose death data has not been released

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.

Child Protective Services Staffing Shortages

In August of 2023, Buncombe County’s Social Services gave County Commissioners a briefing on the current workforce shortages for the Child Protective Services division. The department noted that due to recent resignations and transfers that remaining staff were taking on higher caseloads to keep up with the inflow of new cases. As of July 2023, 35% of the positions within the Investigations team were vacant. In the briefing it was reported that due to the shortage, the division repurposed staff from other programs, expanded job qualifications to include non-traditional degrees, hired contract workers, and increased advertising efforts to recruit more applicants.

The need to coordinate resources:

Community leaders have noted that while Buncombe County has a plethora of organizations and resources for the community to access, there lacks a centralized system which can quickly connect the public to resources such as housing and food assistance. Currently, there are discussions of how to streamline the process of linking residents to vital resources by leveraging NCCARE360.

Childcare Center Closures

In October 2023, seven childcare centers throughout the Western North Carolina Region were closed. The closing of centers has left many families seeking alternative childcare as the seven centers served over 300 children ranging in age from birth to five years old. Many of the families impacted by the closures currently receive childcare subsidies.

Foster Care Home Shortages

In recent years, the number of foster homes have greatly reduced across the State. During the 2019-2023 fiscal years, North Carolina saw an 18% decline in the availability of foster care homes. The decline in the number of potential foster care homes is attributed to a number of families who have decided to no longer foster, and there has been an overall decline in the number of new applicants wishing to foster. The lack of placement options has made it difficult to place children in foster homes and is especially difficult for children who have complex needs. In 2023, for at least 61 nights there were children who slept in Department of Social Services room due to lack of available foster care homes. The lack of foster care homes is also causing an issue within Emergency room departments, as children who are brought in to address mental health issues are without a placement upon discharge.  Therefore, many children are placed on pediatric floors until a solution is determined.

Gender Affirming Care Ban

As of August 2023, anyone under the age of 18 can no longer seek gender affirming care within the State of North Carolina as lawmakers overrode the veto of House Bill 808. This ban prevents children from accessing puberty-blocking drugs, hormone therapy, and gender affirmation surgery. For many Trans youth this ruling has greatly restricted their medical autonomy as their options for seeking care has been eliminated. Gender affirming care is a critical resource as it has shown to help in reducing depression and suicides amongst Trans Youth. In response to the ban, Campaign for Southern Inequality has started the Southern Trans Youth Emergency Project (STYEP) which provides assistance to youth and their families as they are navigating the ban. This project has a four-pronged approach including patient navigation which assists families in navigating their options for medical care within or beyond their State. The project also helps to provide $500 grants to help cover any medical related expenses including travel.

New/Paused/Discontinued Initiatives Since Last CHA

The following is information on new/paused/discontinued initiatves or activities in our community in 2023:

New Initiatives

Community-Based Public Health Response to Violence

Buncombe County was awarded $2.5 million to launch a new community-based safety initiative. Five organizations were awarded a three-year grant to coordinate and provide services and resources in an effort to reduce the occurrence of community violence. The program will work to provide community health workers across the County to help with addressing the root causes which result in community violence.

RAPID HIV and HEP C Testing

 Buncombe County’s Syringe Exchange Program and the Mobile Unit Team partnered together to provide rapid HIV and HEP C testing at the health department. The public can receive rapid testing during designated walk-in hours, during that time a member of the Mobile Team are able to administer the rapid testing as well as coordinate additional care/resources if needed.

Discontinued

Ramada Inn Supportive Housing Project

In an effort to address homelessness in our community, the City of Asheville entered a partnership with a California-based development company who purchased the Ramada Inn to convert the motel into 113 units of permanent supportive housing. The City of Asheville committed to providing three years of funding upon the completion of the project.  Of the 113 units, 50 of those units were designated to serve homeless veterans. Prior to the project, the Ramada Inn operated for a year as a temporary shelter. The project broke ground December 2022 and was slated to be complete by August 2023. The project faced several delays and in January of 2024, the project was halted due to legal issues for the development company.