HNC 2030 Scorecard: Albemarle Regional Services - 2021-2023

Executive Summary

Executive Summary

     Albemarle Regional Health Services (ARHS) and community partners are pleased to present the 2021 Community Health Needs Assessment, which provides an overview of the significant community health needs identified in Pasquotank County, North Carolina.  The goal of this report is to offer a meaningful understanding of the most pressing health needs across Pasquotank County, as well as to guide planning efforts to address those needs. Special attention has been given to the needs of vulnerable populations, unmet health needs or gaps in services, and input gathered from the community.  Findings from this report will be used to identify, develop and target initiatives to provide and connect community members with resources to improve the health challenges in their communities.  The 2021 Community Health Needs Assessment was developed through a partnership between Albemarle Regional Health Services, Sentara Albemarle Medical Center, Health ENC. 

Vision Statement
     The Public Health professionals and programs of Albemarle Regional Health Services are dedicated to disease prevention and the promotion of a healthy environment to reduce morbidity, mortality, and disability through quality service, education, and advocacy.

Partnerships/Collaborations
     Partners in the 2021 CHNA process for Albemarle Regional Health Services include:
     • Albemarle Regional Health Services
     • Gates Partners for Health
     • Healthy Carolinians of the Albemarle
     • Sentara Albemarle Medical Center
     • Three Rivers Healthy Carolinians
     • Vidant Bertie Hospital
     • Vidant Chowan Hospital
     • Vidant Roanoke Chowan Hospital
Local Healthy Carolinians partnerships utilized grass root efforts to ensure community citizen’s opinions were heard and demographic characteristics of participants were considered to ensure that results portrayed an accurate representation of each county as a whole.

Regional/Contracted Services
     The 2021-2022 ARHS CHNA was supported by Health ENC (HealthENC.org), a collaborative initiative of health departments and hospitals in eastern North Carolina that provides support for community needs assessments statewide.

Collaborative Process Summary
     For the CHNA, Albemarle Regional Health Services developed a CHNA Leaders Team to help lead the process. The CHNA Leaders Team included county residents as well as representatives from various local agencies and organizations from throughout the eight-county service area. The CHA Leaders Team members brought a wealth of knowledge and expertise on a variety of issues and populations in the county, and the broad range of backgrounds ensured objectivity throughout the prioritization process. The CHA Leaders Team met three times between April 2021 and July 2021 to review strategies for conducting primary data collection for the CHNA, stay informed of the process, and provide feedback.
     Collaboration between Albemarle Regional Health Services and other local partners made this assessment possible. Many collaborators spent numerous hours attending meetings, collecting survey data, and attending presentations. These partners also played an active role in the priority selection process.

Key Findings
     The CHNA findings are drawn from an analysis of an extensive set of secondary data (over 100 indicators from national and state data sources) and in-depth primary data from community leaders, health and non-health professionals who serve the community at large, vulnerable populations, and populations with unmet health needs. Through a synthesis of primary and secondary data, several significant health needs were identified for ARHS.  These include:

• Access to Health Services
• Cancer
• Diabetes
• Economy
• Exercise, Nutrition & Weight
• Heart Disease & Stroke
• Behavioral Health
• Substance Abuse

Priorities

• Healthy Lifestyle Behaviors
• Access to Healthcare 
• Mental Health/Substance Misuse  

Why Is This Important?

Access to comprehensive, quality health care services is critical to achieve and maintain health, prevent and manage disease, and achieve health equity. 

Partners

• Community Care Clinic
• Sentara Albemarle Medical Center
• ECU Health Chowan Hospital 
• ECU Health Bertie Hospital 
• ECU Health Roanoke Chowan Hospital
• Urgent Care 

Program Description

ARHS offers comprehensive clinical services through each of its eight local health departments, including Primary Care services for uninsured and underinsured clients 18 and older.  Services include:

• Tobacco Cessation
• Weight Management
• Diabetes Screening
• Blood Pressure Screening
• Medical Procedures
• Laboratory Services
• Vaccinations
• Sick Visits

Why Is This Important?

There are a lot of benefits to an active, healthy lifestyle, from preventing disease to reducing stress.  The CDC states exercise and proper nutrition improve overall health and fitness reducing the risk for chronic diseases. The 2022 County Health Rankings reveal that obesity is still on the rise in our service area and leading health problems identified included obesity/overweight and lack of exercise.  Chronic diseases are among the most common, costly and preventable health problems in North Carolina. Lifestyle risk factors, which include nutrition and physical activity, contribute to these diseases. Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer. These are among the leading causes of preventable, premature death.

Partners

NC Cooperative Extension - Pasquotank County, Chowan County

Elizabeth City Pasquotank Parks and Recreation

Perquimans County Parks and Recreation

Chowan County Parks and Recreation

Northern Chowan Community Center

Madhouse Dance Fit

Healthy Carolinians of the Albemarle

Three Rivers Healthy Carolinians

ECU Health Chowan Hospital

ECU Health Foundation - Chowan

Sentara Albemarle Medical Center

Program Description

Albemarle GetFit! is a free fitness and walking program designed to increase the physical activity levels of adults who live or work in Camden, Chowan, Perquimans and/or Pasquotank county. This program offers a variety of fitness activities and nutrition classes, as well as a walking program. Registration is required and prizes are awarded to the most active participants.

This program is overseen by a wellness committee that includes staff from ARHS, recreation departments, cooperative extension, and various fitness instructors. Healthy Living sessions in each county will kick-off the program each fall to include an overview of the program, wellness information, a fitness class, and a healthy meal. Walking is encouraged while providing free fitness classes including, but limited to, Zumba, Kickboxing, Beginner's Boot Camp, Yoga, Line Dancing and Strength Training. Classes are provided weekly based on funding availability and class attendance/participation. ARHS also partners with Cooperative Extension to provide cooking/nutrition classes, including the Med Instead of Meds program, in each county. Wrap-up sessions are held at the end of the program to evaluate program success including pre and post screening data.

The goal of Albemarle GetFit! is to promote physical activity and nutrition to reduce the risk of chronic disease and improve quality of life.   Sessions start in the fall and run through the spring of each year.

Partners

• Local Schools 
• Faith-based Organizations
• NC Cooperative Extension 
• Local Growers and Farmers 
• Local Markets and Roadside Stands 
• Local Food Pantries
• Food Bank of the Albemarle 
• Healthy Cornerstores

Program Description

Access to healthy foods is important in the fight against chronic diseases and crucial to a healthy lifestyle. We are working to improve and increase access to fresh fruits and vegetables throughout the ARHS service area, using the following strategies:

• Supporting farmers markets and roadside stands by increasing SNAP/EBT acceptance and fruit and vegetable incentive programming
• Promoting community use of grounds and facilities for fruit and vegetable production by supporting community/school gardening and farming
• Resource sharing through a regional healthy foods coalition of representatives supporting community food security and healthy eating
• Providing Nutrition Education 
• Partnering with nutrition education providers and fresh produce retailers to offer fruit and vegetables through Produce Prescriptions
• Assisting with the development of long-term plans that address healthy food access through policy and other environmental level programming

What We Do

Faithful Families works directly in communities of faith to promote health for individuals, families, and local communities. The practice-tested program is open to all faith and religious traditions and engages faith communities in health education, environmental changes to support health, and community-wide health initiatives.

Who We Serve

Faith based communitites

How We Impact

Program facilitators and Lay Leaders are trained to co-deliver Faithful Families’ Eating Smart and Moving More Lessons, which includes nine sessions on healthy eating and physical activity strategies, including nutrition, meal preparation and cooking, food safety, and increasing daily physical activity. Through group discussions, recipe taste tests , and activities, individuals and families are encouraged to set goals to lead healthier lives. The curriculum also prompts discussions about changes that can be made in their organization and local community.

Partners

Healthy Carolinians of the Albemarle

Sentara Albemarle Hospital

Sentara Cares

Pasquotank County Cooperative Extension Office

Pasquotank County Department of Recreation

Gateway Community Health Center

Pasquotank  County Churches

Pasquotank County Schools

Program Description

ARHS works with community partners to implement programs, activities, and initiatives aimed towards reducing the burden of chronic diseases such as heart disease, diabetes, and strokes on our community through community education and the promotion of healthy eating, physical activity, and  medication management. Such activities and initiatives include, but aren’t limited to:  Diabetes Prevention Programs, Diabetes Support Groups, Cancer Support Groups, and the Know it, Control It Program.

Why Is This Important?

Behavioral and mental health doesn't discriminate. We are all impacted mentally at some point in our life. Having equitable access to mental health resources, without judgement or stigma, would help create a community that supported mental health and allow anyone who wanted or needed mental health services the ability to recieve those services.  Substance use disorders are chronic or recurrent conditions that, like other chronic illnesses, require ongoing care and treatment for individuals to regain health and maintain recovery. As with any chronic disease, prevention, identification, treatment, recovery services and support are essential to ensuring positive health outcomes.

Partners

East Carolina University 

Program Description

ARHS Behavioral Health is an ADULT outpatient program, which strives to meet the Emotional Health needs of our region through comprehensive Nursing, Counseling, and Psychiatric interventions.  Services include:

• Screening and Referrals
• Outpatient Therapy/Counseling
• Comprehensive Clinical Assessment
• Nursing Services
• Psychiatric Evaluation
• Psychiatric Medication Management
• Emotional Wellness Support Group
• 24/7 Nurse on Call
• Evening Appointments
• Interpreter Services

Services are provided by ARHS Clinical Staff,  ARHS Licensed Clinical Social Workers, and through the ARHS Behavioral Health Program via Telepsychiatry with East Carolina University providing Psychiatric Evaluation and Psychiatric Medication Management.    All new patients are referred by a primary care provider or other medical provider to ARHS RN and LCSW  who then conduct a Comprehensive Clinical Assessment before scheduling with Dr. Muppavarapu.  ARHS communicates with medical providers to coordinate care.  ARHS accepts private insurance, Medicaid, Medicare, and employs a sliding scale fee with proof of income.

Partners

Gates Partners for Health, Healthy Carolinians, Three Rivers Healthy Carolinians, Region 9 Oral Health Alliance, NENCPPH, WIC, area healthcare providers, school personnel (School Health Alliance Councils, guidance counselors, school nurses), Triple P providers, ECU Health, Healthy Foods Coordinator, Healthy Beginnings Coordinator, Pediatric Asthma providers and Child Fatility Prevention Teams

Program Description

Provide and conduct presentations to regional collaboratives, partner and county commissioners regarding the benefits of Tobacco Free government buildings, grounds, vehicles, parks/recreation areas and smoke free public places. Promote the benefits of cessation and tobacco free living during events such as the Great American Smokeout, Take Down Tobacco and Kick Butts Day. Encourage cessation efforts within schools and support school personnel to attend Duke/UNC Tobacco Treatment Specialist trainings and CATCH My Breath trainings. Be available to promote evidence based curriculum and trainings through presentations and handouts for resources on tobacco prevention, suspension and tobacco/vaping cessation. Spread the message regarding QuitlineNC via social media, mass media campaigns, cards and brochures, at community events and through presentations, among area providers.

Partners

Law Enforcement

Emergency Medical Personnel

Peer-Support Specialists

Department of Social Services (DSS) Agencies

Mental Health Agencies

County Representatives

The Court System

County Government and Elected Officials

Schools Systems

Medical Providers

Recovery Partners

Other Community Partners

Program Description

The Albemarle Overdose Prevention Coalition (AODPC), works to address the growing problem of addiction and substance use disorder in the Albemarle region.

The goal of AODPC is to align partners to better educate the community on addiction and recovery, provide support and resources to users, and ultimately cure addiction in the Albemarle region.

The AODPC actively engages partners through our Regional Overdose Prevention Action Plan. The following areas highlight the work of the AODPC, community partners, and information and resources available as we work to prevent addiction and promote recovery:

Provider Outreach and Education

The AODPC has partnered with Eastern AHEC to offer educational courses and resources to providers throughout the region. In addition, resources on the STOP Act, Controlled Substance Reporting System, Naloxone availability and Medication Assisted Treatment options have been shared.

Safe Medication Storage and Disposal

Even legal drugs can be gateway drugs. Four out of five people addicted to heroin tried prescription opioids first. Prevent diversion by locking up prescriptions and disposing of leftovers.

Treatment and Recovery Resources

AODPC partners with local and state agencies to provide programs, resources and facilities to assist in treatment and recovery.

Partners

• Trillium
• Local Churches 
• Mobile Crisis 
• PORT 

Program Description

Provide Gate Keeper Training for suicide prevention, which includes:

• Living Works Faith - Living Works Start and Living Works Safetalk
• Mental Health First Aid
• Applied Suicide Intervention Skills
• Question, Persuade, and Prefer

Progress on CHIPs

Our Scorecard outlines the efforts being made in the eight county ARHS region to address the following health priorities identified in the CHA: 

• Healthy Lifestyle Behaviors
• Access to Healthcare 
• Mental Health/Substance Misuse 

We strive to keep our scorecard as up to date as possible. Click the document symbol beside each program to learn more about the programs and initiatives taking place to improve health outcomes in the ARHS region. You can read the story about progress on each performance measure by opening the "plus" sign next to each performance measure.

Morbidity and Mortality Changes Since Last CHA

• We did not identify any other major morbidity or mortality changes in 2022 in the ARHS service area as Heart Disease and Cancer have remained the leading causes of death in recent years 
• Albemarle Regional Health Services has seen an overall decline in COVID-19 morbidity but we continue to provide surveillance

• According to the 2022 County Health Rankings, the prevalence of Diabetes continues to be higher than the state rate (11%) in all ARHS counties except Camden, Currituck, and Perquimans (B 15, C 10, Ch12, Cu 9, G 12, H 15, Pa 12, Pe 11)

Emerging Issues Since Last CHA

• Gun Violence
• School Agression/Violence
• Youth Tobacco Cessation
• Increase in Human/Sex Trafficking
• Amount of time it takes to get appointments for healthcare visits

New/Paused/Discontinued Initiatives Since Last CHA

New Initiatives-

• Healthy Opportunities
• Faithful Families
• Community Gardens

Discontinued Initiatives-

• Gates County Diabetes Support Group has not met since COVID

Progress on CHIPs

Our Scorecard outlines the efforts being made in the eight county ARHS region to address the following health priorities identified in the CHA: 

• Healthy Lifestyle Behaviors
• Access to Healthcare 
• Mental Health/Substance Misuse 

We strive to keep our scorecard as up to date as possible. Click the document symbol beside each program to learn more about the programs and initiatives taking place to improve health outcomes in the ARHS region. You can read the story about progress on each performance measure by opening the "plus" sign next to each performance measure.

Morbidity and Mortality Changes Since Last CHA

• We did not identify any other major morbidity or mortality changes in 2023 in the ARHS service area as Heart Disease and Cancer continue to remain the leading causes of death in recent years 

• According to the 2023 County Health Rankings, the prevalence of Diabetes continues to be higher than the state rate (11%) in all ARHS counties except Camden, Currituck, and Perquimans (B 15, C 9, Ch12, Cu 8, G 11, H 14, Pa 11, Pe 10)

Emerging Issues Since Last CHA

• Firearm misuse deaths among youth
• Vaping in younger youth
• Boating safety
• Distracted driving

New/Paused/Discontinued Initiatives Since Last CHA

New Initiatives-

• Gates County GetFit! pilot program ( planning occured in 2023 - actual program will take place in 2024)
• Hispanic Food Distribution and Tasting program
• PW Moore Community School Literacy Family Night
• Albemarle GetFit! recipe tastings
• Increased number of staff trained as Child Passenger Safety Technicians

Paused Initiatives-

• Gates County Cancer Support Group has been paused due to staffing changes and a lack of participation

Discontinued Initiatives-

• Maternal Child Health of the Albemarle Region Collective (MARC)