Executive Summary

2019CommunityHealthAssessment_ExecutiveSummary_1.pdf

Priorities

Three priorities were identified, which are:

• Access to Care*
• Health Behaviors
• Health Equity

*During the time of action planning, it was uncertain how NC would adopt and approach Medicaid Transformation. This gave us uncertaintity with reasonable outcomes that would be beneficial to our community.  Due to the uncertainities, an action plan was not developed for Access to Care.*

What Works

Low Cost/No Cost Solutions 

• Educate the community on healthy behavior change and best practices as it relates to alcohol consumption and storage. 
• Educate and train merchants on the importance of checking ID and not selling to minors 
• Community educational campaigns around alcohol, equity, awareness and resource availability.

 Innovative ideas 

• Work with county policy makers to regulate and enforce alcohol sales to individuals under 21 to help reduce the sale to minors (if any) 
• Work with local businesses to create a Good Neighbor Business Network that will allow businesses to opt in and utilize best practices as it pertains to alcohol sales.

Additional Research 

• Work with NC DHHS and local data managers to conduct an ongoing analysis on local alcohol outlet density and determine if the density is greater than the demands of the population and/or communities of color. 
• Is there an abundance of alcohol outlets in communities of color? 
• Are there a high number of off-premise outlets within 5 miles (or less) of middle and high schools? 
• Look into the Good Neighbor Business Network initiative from Durham County and replicate their successful efforts

Why Is This Important?

Underage drinking and drug use is not a rite of passage. Early use of substances hurts our young people and hurts our community. By working together, we can help youth succeed and reach their true potential.

Strategy

Action Plan

Overall Strategies:

• Introduce Results-Based Accountabilty (RBA) as a framework for getting from Talk to Action quickly
• Engage network members in Clear Impact Scorecard to track program performance
• Make RBA training available to the network

What We Do

Our mission is to advocate, guide and assist Orange County in planning and implementing health care strategies to promote healthy lifestyles, improve health status and prevent premature death and injury for all residents in the county regardless of age, race, income, or educational level. The overall goal of the program is to reduce health disparities.

Who We Serve

We serve all individuals who live in work in Orange County.

How We Impact

Coalitions work together and collaboratively as a network of agencies and citizens partnering to promote health and wellness in Orange County. Members of Healthy Carolinians of Orange County, and related coalitions, are representatives from schools, human service agencies, churches, civic groups, businesses, local government, UNC Chapel Hill, health care organizations including UNC Healthcare, and concerned members of the public.

What Works

There are three areas of health equity that the Health Equity Council will focus on:

• Education and Awareness - Health inequities based on race have been largely blamed on the individual. Historically, however, systemic racism has had much to do with inequities in Black, Indigenous, People of Color (BIPOC) communities and other marginalized and vulnerable populations. The depth of structural racism in our community is invisible to many. The Health Equity Council aims to educate community members, agencies, businesses, and others on various health and racial equity topics. Increased educational efforts bring awareness to how systems in Orange County are structured to produce health inequities for marginalized groups and allow participants to learn how to dismantle those systems. 
  • Community Curriculums 
  • Community Workshops and Training

• Data - The Health Equity Council realizes that disaggregated data is not as readily available in Orange County on a neighborhood level. A racial equity index for Orange County is essential in understanding where and for whom interventions should be directed. Overlaying this index with political determinants of health will help dismantle laws, ordinances, and other policies that perpetuate health inequities in Orange County. 
  • Qualitative Research 
  • Racial Equity Index

• Health Equity in COVID-19 Recovery -The pandemic opened many eyes to the inequitable conditions and circumstances that caused BIPOC communities to be hit harder by COVID-19. As we move through equitable vaccination efforts, now is the time to plan for recovery. The Health Equity Council encourages continued vaccination planning for people of color communities and other vulnerable populations and systemic policy change.
  • Systemic Policy Revision

Strategy

Inform the One Orange Racial Equity Index

Story Behind the Curve

The Human Rights and Relations Department was recenlty renamed to be the Office of Equity and Inclusion and is now housed in the County Manager's Office. 

In June 2022, Orange County leadership named Dr. Shameka Fairbanks as the county’s first Chief Equity and Human Rights Officer. This position will further the Board of Commissioners’ goal of fostering a community culture that rejects oppression and inequity.

As Chief Equity and Human Rights Officer, Fairbanks will be responsible for implementing Orange County’s One Orange goals. Additionally, the position leads the Government Alliance for Racial Equity and the Diversity, Equity and Inclusion Workgroup.

There are five (5) pillars that the work of One Orange will fall under:

• Pillar 1 – Training and Organizational Capacity
• Pillar 2 – Community Engagement
• Pillar 3 – Racial Equity Index
• Pillar 4 – Racial Equity Assessment Lens
• Pillar 5 – Evaluation and Accountability

What Works

• Training
  • Organizational capacity is a key component in advancing racial equity efforts. This includes a plan to provide training to build capacity and advance racial equity in countywide systems. It is important to provide adequate racial equity training to ensure that employees, Elected Officials, advisory boards and commissions, community partners and other stakeholders build a foundation including definitions of key terminology and commonality.
• Community Engagement 
  • To effectively remove race as a predictor of success, residents and employees of color should also be engaged as subject matter experts on institutional barriers and the strategies to dismantle those barriers. This engagement will make for better procedures, policies, and programs.
• Racial Equity Index
  • The use of data and analytics is integral to the work of One Orange to present a descriptive picture of where the county and municipalities are currently in racial equity work, and to track progress overtime.
• Racial Equity Assessment Lens 
  • Evaluation of existing and new policies, practices, services and initiativesis is imperative to advancing racial equity efforts.
• Evaluation and Accountability 
  • The RBA framework provides a disciplined, data driven decision-making process to help local governments take action to solve problems. RBA is embedded in the Racial Equity Assessment Lens that starts with the desired result and works backward to the means, to ensure the desired results works toward community results with stakeholder-driven implementation.

Why is this Important

In Orange County, Black and Brown people face the most inequities.  Data here in Orange County shows that income disparities, homeownership rates and education achievement gaps continue to persist and the county’s focus is not on equality but equity.

Racial equity is specifically about making sure our policies and practices no longer cause harm to Black and Brown communities.  The framework should be seen as a working document which will change with time, and part of the framework is to acknowledge how government policies and practices have historically contributed to racial disparities in the community.

Why Is This Important?

According to Health Equity Council members, there are stories in the community that influence health equity and health disparities. While Orange County isn’t vastly unique from other places, communities of color are experiencing issues related to:

• access to care and prenatal care
• stress from racism and simply being black
• lack of black doctors and other health professionals of color
• medical racism
• environmental exposures
• mass incarceration
• structural racism

There are also significant advantages for white community members:

• being listened to by medical professionals
• increased access
• being able to inform the practices of healthcare providers who structure services to normalize white comfort which in turn may be uncomfortable for black community members

Health inequities in Orange County affect everyone and communities of color are disproportionately. Achieving health equity will take the work of all sectors and industries - understanding the root causes of health inequities, how all aspects of a community affects health, and strategizing together to create systems with policies and practices that are equitable.  

Progress on CHIPs

Healthy Carolinians of Orange County (HCOC) and its partners went through an action planning process in 2020 and the early part of 2021 to identify potential strategies to address, at the community level, around 1) access to care, 2) health behaviors and 3) health equity. Due to COVID-19, each committee of HCOC experienced barriers that delayed the action planning process and the outcomes. Similar to every other agency and coalition, majority, if not all, of our members had to deal with transitioning to work from home, caring for children and school responsibilities while working from home, assuming new or modified responsibilities as a result of COVID-19, and/or transitioned out of their role or the county. Through it all, the committees continued to meet (on a limited schedule) and think through efforts that could not only be useful to Orange County post COVID, but could also incorporate new COVID protocols and requirements.

For the next four years, HCOC will make efforts around each priority area and implement and support new or existing efforts to help improve access and the overall health and well-being of those who live and work in Orange County. The Access to Care committee will help to ensure that all individuals receiving services in Orange County will have everything they need, with no limitations, as it pertains to transportation, healthcare, prevention, as well as, intervention and treatment services. The Health Behaviors committee will focus on alcohol access and alcohol outlet density and work to ensure that all Orange County supports safe and responsible use of alcohol. The Health Equity Council will work to ensure that all members of the Orange County community have meaningful access to resources and supports to define, maintain, and improve their physical, mental, and social health and wellbeing.

To get involved or to assist with the ongoing work of HCOC, around any of the three focus areas of Access to Care, Health Behaviors or Health Equity, email us at:
hcoc@orangecountync.gov or call 919-245-2440.

Changes in Morbidity and Mortality Data since last CHA

Emerging Issues

 While OC is leading the state in vaccinations with over 60% of community members fully vaccinated, there are still individuals who are at a disadvantage and OCHD will not rest until everyone who wants a vaccine is able to get a vaccine. In an effort to ensure that all community members have access to the vaccine, the OC Mobile Vaccine Team is ready to vaccinate people who are homebound or are otherwise unable to travel to a vaccine clinic. To date (June, 2021), the OC Mobile Vaccine Team has administered the vaccine to 44 homebound individuals. The most reported challenge of this program has been identifying those in need. To refer individuals for the vaccine, who may be encountering challenges, visit www.orangecountync.gov/MobileVax or call 919-245-6127.

During an emergency the county’s EOC is activated as well as the Joint Information Center (JIC). The JIC operates out of the Health Department and serves to unify the information network so that all community members receive consistent messaging about the emergency as it evolves. It also serves as a centralized portal for information and complaints. Messaging is available in multiple languages and is delivered through multiple channels and in a variety of formats in order to bridge the digital and literacy divide. The JIC and the larger communicators workgroup meet often to address disinformation, review new COVID-19 guidance and to disseminate ready to use resources on a regular basis.

OCHD Pandemic Response by the Numbers (from January 25, 2020 to June 28, 2021)

New/Discontinued Initiatives

Education, employment, income, family and social support, access to affordable and quality healthcare, and safety all provide the foundation for overall health and wellbeing. Social and economic factors have a huge impact on where and how one lives, jobs obtained, the care provided, and one’s overall day-to-day experiences.

Health Care
Orange County has a strong health care community that includes a nationally-ranked hospital system, an accredited School of Public Health, a federally qualified health center, a local public health department, a medical and dental school, and various private medical practices. Even though OC has a physician rate of 119.62 per 10,000 population, residents
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continue to report barriers accessing health care services. Some voiced barriers include:
1) no medical insurance
2) the concentration of health care resources in the southern part of the county
3) inadequate transportation systems in the central and northern part of the county
4) language barriers
5) perceived discrimination or racism within health care facilities

Insurance
According to small areas health insurance estimates, 10.5% of OC residents 0-65 years of age are currently uninsured, compared to the NC rate of 12.5%. NC children and seniors show higher rates of coverage, largely due to Medicaid and Medicare. Having health insurance provides individuals access to the health care system. A lack of coverage creates barriers that can limit or prohibit individuals from receiving the health care that they need and can cause an individual to have poor health status, late or no diagnosis and/or premature death.

NC’s Medicaid program currently uses managed care in a limited way, where primary care case management is done through Community Care of North Carolina, the LME/MCO system for behavioral health services, and the Program of All-Inclusive Care for the Elderly (PACE).

OCHD contracts with Community Care Physician Network (CCPN), which is a Clinically Integrated Network (CIN) in NC. CCPN then contracts with all of the PHPs that are eligible to provide coverage in Orange County on our behalf (AmeriHealth Caritas, BCBSNC, Carolina Complete Health, United Healthcare, and Wellcare), and are able to negotiate contracts with better fees and conditions for a large number of NC counties.

Transportation
On March 5, 2021, Orange County Public Transportation (OCPT) launched MOD (Mobility On Demand), an innovative pilot program that will provide flexible and dynamic transportation service within the Hillsborough service area. Orange County’s MOD program will cost $5 per trip and will be available on Fridays from 5 p.m. to 9 p.m. and Saturdays from 9 a.m. to 5 p.m.

Similar to companies like Uber and Lyft, Orange County MOD vans will accommodate riders with disability needs and users will have the option to request a same-day ride through a smartphone app called TransLoc. The app will provide passengers with an estimated pick-up time, track the MOD van’s location in real-time, and alert them when their ride is about to arrive.

Chapel Hill Transit provides transportation service to two UNC Health vaccination clinics and OCHD’s vaccination clinic, which was previously provided at the RR Lot. Chapel Hill Transit operates GoTriangle’s 420 route, which provides service to UNC Health vaccine clinic in Hillsborough.

Foods consumed, lack of exercise, use of seatbelts, substance use (i.e. tobacco and alcohol) and sexual activity all affect ones overall health. Health behaviors are not always determined by a choice to be healthy or unhealthy, however, it is important to note that where one lives, learn, work and play, as well as social and economic circumstances and trauma exposure often dictate the ability to make healthy choices.

Tobacco Prevention and Control during COVID-19
OCHD’s Tobacco Prevention and Control Program is evidence based, personalized and intentional in its approach to tobacco cessation. COVID is an illness that can impact the respiratory system, and in individuals who smoke or use tobacco COVID can have a devastating impact on the health of the lungs. OCHD pivoted the ways in which services were delivered to meet the needs of community members interested in quitting tobacco during the pandemic.
 

FreshStart Group Support Classes
FreshStart is a tobacco cessation class that meets one hour per week for four weeks and offers participants educational cessation information, group support, and 12 weeks of free Nicotine Replacement Therapy (NRT) Products. As a result of COVID, the FreshStart Program had to adapt to community closures and pivoted from face-to-face classes to virtual classes. The virtual classroom provided community members the ability to access the course from their home environment, which resulted in increased registration, participation, and group support. Like most things, COVID created various challenges to the normal way of operating and providing service. The first challenge was the need to mail all course material and NRT products rather than distributing them in person. The second challenge was the need for all participants to have access to a smart phone or computer with reliable WIFI connection.

Individualized Tobacco Treatment Services
Individualized Tobacco Treatment Services offers individuals 12 weeks of counseling and NRT products to those interested in quitting smoking, vaping or using any other tobacco products. Due to COVID and office closures these services adapted and changed from weekly face-to-face meetings to weekly telephonic meetings. The benefit of telephonic and virtual sessions was the ability for participants to access necessary support at their convenience, which yielded more referrals from the Orange County Medical and Dental clinics and area healthcare providers, and more satisfied participants. Currently, this programmatic service is seeing over 20 patients at varying stages of cessation in their smoke free journey, ranging from 30 days to 7 months.

The UNC Tobacco Treatment Program (formerly the Nicotine Dependence Program) has provided leadership for implementing comprehensive tobacco use treatment services, education and training, and dissemination of resources for promoting tobacco free communities for the past 12 years.
UNC’s Tobacco Treatment Program (TTP) provides services across the UNC Health Care System, regardless of ability to pay. Services include:

• UNC Family Medicine Center: Open to all community members
• NC Cancer Hospital: TTP’s on-site specialists engage patients from across the state who are fighting cancer.
• UNC Hospitals: Trained specialists ensure that patients receive medications for withdrawal upon admission to the hospital, resources for remaining tobacco free after discharge, and follow-up support.
• Worksite Programs: TTP works with local and regional employers, including UNC Health Care and the Town of Chapel Hill, to help their employees become and remain tobacco-free.

Orange Partnership for Alcohol & Drug Free Youth (OPADFY) connected with a Pediatric Physician to facilitate the development of a pediatric smoking/vaping cessation program and a youth vaping prevention program. That partnership yielded the initiation and implementation of a fellowship with the UNC Pediatric Pulmonary team where their staff will use this program to assist youth in quitting vaping, particularly those suffering from e-cigarette or vaping product use-associated lung injury (EVALI).

Prescription & Opioid Drug
Decades of prescribing more opioids at higher doses have led to a rising number of opioid overdose deaths creating a public health crisis in North Carolina to include Orange County. At the end of 2019 and prior to the COVID-19 pandemic, UNC Medical Center and OCHD partnered to further coordinate efforts to address this epidemic in our community. This partnership will be a 3-5 year commitment to work with stakeholders in the opioid use disorder (OUD) and substance use disorder (SUD) community in OC. This partnership will build a more resilient infrastructure equipped to assess community needs to current and potentially the next wave of the opioid epidemic. The NC Opioid State Action Plan will serve as the foundation for the work with the below three priorities to address:

1) education
2) reduce oversupply of prescription opioids
3) expand treatment and recovery oriented systems of care

It is the hope to resume this group in 2021-2022, once things calm down around COVID-19, the vaccine, and reallocation of time back to this effort among both UNC Medical Center and OCHD.

Currently, there are eight permanent drop box locations in OC, to help dispose of expired and unwanted medications. Permanent drop boxes are located within all of OC’s police departments (Carrboro, Chapel Hill and Hillsborough), the Orange County Sherriff Office, Hillsborough Pharmacy, Walgreens, and three within UNC Health (two at the Chapel Hill campus and one at the Hillsborough campus).

Alcohol
The third leading cause of preventable death in NC is excessive drinking, and has been trending upward from 2012-2017. Excessive drinking is defined as binge drinking (4-5 drinks or more in one sitting by women and men), heavy drinking (8-15 drinks per week for women and men), and any drinking by pregnant women or people under the age of 21. Nine out of 10 excessive drinkers are not dependent on alcohol but may not realize that excessive drinking is associated with increased risky behavior, violence, suicide, homicide, vehicular accidents and/or multiple chronic diseases.

While the number of alcohol related ED visits, among OC minors, has declined from 2017 – 2019, alcohol continues to be the number one most frequently used substance among OC youth. There is strong evidence that alcohol outlet density restrictions can help reduce the rate of alcohol consumption, violent crime, individual alcohol consumption and underage drinking.

Racism and Health
“Racism structures opportunity and assigns value based on how a person looks. The result: conditions that unfairly advantage some and unfairly disadvantage others. Racism hurts the health of our nation by preventing some people the opportunity to attain their highest level of health. Racism may be intentional or unintentional and operates at various levels in society. Racism is a driving force of the social determinants of health (like housing, education and employment) and is a barrier to health equity”.

OCHD acknowledges that public health is a system that was and continues to be structurally and foundationally built on racist policies, practices, and procedures. Due to this history, OCHD must actively work to gain the public’s trust and grow the department to become a more equitable system.

OCHD also acknowledges that our county’s marginalized populations face barriers across systems due to racial inequities in housing, banking, education, employment, etc. all of which contribute to poor health outcomes. This is why Health Director Quintana Stewart declared structural racism a public health crisis.

OCHD’s Racial Equity Commission (REC) wanted to find a way to share resources and encourage OC’s community to enter the equity conversation. The health equity webpage was created to help others in the community grow in this work, to show the community the strides made in this work, and to help stay accountable to the community.

OC’s Health Equity Council (HEC) was formed when OCHD received funding from the NC Office of Minority Health and Health Disparities to address the health status gap between racial/ethnic minorities and the general population. Members of HEC provide input and approve plans and budgets that outline action steps to advance health equity, address social determinants of health, reduce health disparities, and impact Culturally Linguistically Appropriate Services (CLAS) Standards.

To assist community partners with COVID-19 relief, HEC used existing funding to support language access as it relates to interpretation and translation needs. HEC is open to all community residents, businesses, agencies, and organizations. HEC’s 2021-2024 action plan focuses on increasing educational opportunities and raising awareness of health equity in OC, increasing access to qualitative data by engaging community residents and working to inform the development of the Racial Equity Index, and improve health equity in COVID-19 recovery efforts by advocating for systemic policy change and continuing to vaccinate marginalized and vulnerable populations. To get involved, call 919-245-2405.

Race/Ethnicity and COVID-19
While race and ethnicity are markers for other underlying health conditions, including socioeconomic status, access to healthcare, and exposure to viruses, it also proves to be a marker for COVID-19. Early in the pandemic it quickly became clear that marginalized communities were being disproportionately affected by COVID-19, in particular the Hispanic/Latinx community. To help reach and address the concerns of COVID-19 among the Hispanic community, OCHD and Orange County Human Rights and Relations launched a video series called “Cafecitos con el Condado de Orange” (Coffee with Orange County) which aims to address the questions and concerns of the Hispanic community.

In response to this urgent need an existing Latinx Equity group began meeting weekly. The group includes attendees from various organizations from within the county and the state that identify as Hispanic/Latinx and are deeply involved with the Hispanic community. Topics have included health, housing, food scarcity, school closing, the challenges of virtual learning, and much more. In addition to sharing resources, the Latinx Equity group also collaborates on messaging that is tailored to the Hispanic community.

Human Services COVID-19 Response
December 21, 2020, OC created and launched a Human Services Consulting Group to help reduce vaccine barriers for people of color and other historically marginalized groups in OC. This is a racially diverse group of doctors, community center directors, public health educators and communicators, and County and non-profit staff representing more than 15 organizations. While the group originated as a result of COVID, the plan is to make the Human Services Group a subcommittee of HEC which will allow it to continue to guide and support the equitable distribution of vaccines and advocate for systemic policy change in COVID-19 recovery efforts.

The focus of the Human Services Consulting Group is to:

• Align County departments, who provide direct human services to residents, with non-profit service providers to identify historically marginalized groups (LGBTQ+, people of color, disable, etc.) across the County who are facing barriers to getting the COVID-19 vaccine and finding ways to remove those barriers.
• Identify locations and host organizations for pop-up community vaccine clinics, and support those host organizations by directly reaching out and getting people signed up for appointments. During the early months of the vaccination effort, demand for vaccines was so high that people who had the free time and the technology to sign up often took vaccine appointments. The direct outreach conducted, along with trusted community organizations, was key to ensuring that historically marginalized groups had access to the vaccine.
• Work to identify homebound residents to get them vaccinated at home.
• Help establish a partnership to vaccinate unsheltered individuals in the OC.
• Report community feedback to the vaccination leadership team to help continuously improve the OC’s practices. Community feedback led to improvements like centering community volunteers at community vaccination events, ensuring that police officers stayed in the background of vaccination events, and ensuring messages were sent in the ways and in the languages that would be most effective.

The work of the Human Services group, along with that of OCHD’s vaccination team, has helped lead to vaccination rates among OC’s Black and Latinx residents that are higher than their share of the population in the County.

1 NC DHHS (2021). NC SCHS: Statistics and Reports: County Health Data Book. Accessed from https://schs.dph.ncdhhs.gov/data/databook/
2 Orange County (2021). Orange County Health Department: COVID-19 Dashboards. Accessed from https://www.orangecountync.gov/2643/COVID-19-Dashboards
3 Orange County (2019). 2019 Orange County Community Health Assessment. Accessed from https://www.orangecountync.gov/DocumentCenter/View/11246/2019-COMMUNITY-HEALTH-ASSESSMENT-web
4 NC DHHS (2019). New Data Dashboard Illustrates State, County Impacts of Excessive Alcohol Use in North Carolina. Accessed from https://www.ncdhhs.gov/news/press-releases/new-data-dashboard-illustrates-state-county-impacts-excessive-alcohol-use-north
5 County Health Rankings (2021). Alcohol Outlet Density Restrictions. Accessed from https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/alcohol-outlet-density-restrictions
6 APHA (2021). American Public Health Association: Racism and Health. Accessed from https://www.apha.org/topics-and-issues/health-equity/racism-and-health

Progress on CHIPs

Health Behaviors

Alcohol

We have a result that "all Orange County supports safe and responsible use of alcohol" and a Performance Measure to identify the number of community education opportunities around alcohol prevention and awareness. 

In December, 2021, Healthy Carolinians of Orange County, along with the Orange County Health Department, Chapel Hill Campus and Community Coalition, Insight Human Services, Orange Partnership for Alcohol & Drug Free Youth and UNC Bowles Center for Alcohol Studies hosted our first community conversation; “Preventing Underage & High-Risk Drinking.  The virtual event addressed what we know about alcohol, what we know locally about alcohol, what we know about alcohol and COVID-19, and what works to address the problem.  The community conversation revealed, and sparked conversations, around:

• Alcohol being the 3rd cause of death in the US (3.5%).
• Harms from alcohol use are not confined to drinkers but is the drug that has the most harms borne to others by being physiologically and socially disinhibiting.
• Whites have the highest rate of heavy drinking.
• Whites and Native Americans are at highest risk of alcohol use disorder.
• Approximately 5,500 UNC Chapel Hill undergrad students are binge drinking at least biweekly.
• Excessive drinking costs Orange County $111.8 million, with 43% of those costs costing the drinker, 45.6% costing the government, and 11.3% costing others (i.e. victims, insurance, etc.).

Orange Partnership for Alcohol and Drug Free Youth’s expansion of the youth empowerment program, Alcohol and Drug Abuse Prevention Team (ADAPT), occurred within 2 middle schools, as well as at the high school level. Youth were trained in substance use prevention, to include environmental strategies, data collection, environmental scans, alcohol, and vaping 101. Peer interviews were conducted to include merchant education and follow up, and a Project Alcohol Sticker Shock (PASS) campaign. PASS was conducted at Food Lion, during the holiday season, and included placing warning messages on approximately 2,000 alcohol products targeting adults. Qualitative data informed the coalition that the use of vapes and alcohol are the most frequently used substances among minors. The most valuable information ADAPT members shared, based on one-on-one peer interviews included; the need for supports for those who want to quit and the realization that most parents do not talk with their children about the harms related to substance use, with the least frequently discussed substance by parents being prescription misuse, and cannabis being the second. This information is informing the coalition as it discerns action plans for the future.

Orange Partnership increased active engagement of parents, specifically among the Spanish speaking communities, by holding “Train the Trainer” parent education workshops. Orange Partnership was able to partner with other programs who frequently service the Latinx population to ensure culturally and linguistically sensitive and appropriate programming was occurring. They worked closely with Family Success Alliance (FSA), a program of the Orange County Health Department, created to address poverty within vulnerable communities in Orange County and El Futuro, a non-profit outpatient clinic that provides comprehensive mental health and substance use services for Latino families. These partnerships enabled Orange Partnership to expand parent education and outreach to an often difficult population to reach due to language barriers. The Orange County Pre-Arrest Diversion (OCPAD) program added a parent pilot program, Power of Parents, to provide education to individuals who have been cited with aiding and abetting underage drinking or other underage drug use. These two opportunities work to increase awareness and provide skill building for parents regarding youth substance use prevention.

Another Performance Measure is to track the percent of passed compliance checks occurring in Hillsborough Town Limits.  This measure is performed and maintained by Orange Partnership, as their scope is limited to the northern part of Orange County.  Their last update was performed in 2019 and accounted for data between 2014-2019.

Tobacco Prevention & Control

It has come to our attention that youth have been constantly increasing use of tobacco, specifically related to vaping.  The school systems, both Orange County Schools and Chapel Hill-Carrboro City Schools have reached out to solicit assistance is educating their staff to help reduce overall student use with specifics around policy.

At the request of Orange County High School Principal, Assistant Principal and Vaping Task Force, a one page resource guide of evidenced based Tobacco Prevention and Cessation Programs for youth ages 8 – 18 was developed and distributed.  This guide is a resource for administrators, staff, parents, educators, school nurses, school social workers and students on what prevention and cessation programs are available and how to access these programs.

Our Tobacco Prevention & Control Manager has met, several times, with the Orange County School District's Vaping Task Force to discuss
their current District Disciplinary Policy as it relates to tobacco use, specifically those students who have been caught vaping.  The school district indicated that the problem has grown significantly and administrators are particularly concerned as they have had to incur expenses due to the smoke alarms being set off due to students vaping in the restrooms.  During these meetings it was discussed that each school within the district has it's own separate disciplinary policy and enforcement.  It was discussed and decided that this issue needs to be brought to the entire school board to develop 1 consistent disciplinary policy for tobacco and vaping infractions.  Additionally, the Vaping Task Force felt it important that this policy be cognizant that disciplinary policies need to be equitable to all of the student body and that offering cessation options as opposed to punitive discipline would be a better option as it would achieve the goal of engaging youth in improving their own health.  

While the policy discussion happened after school was complete for the 2021-2022 year the Vaping Task  Force continues to meet regarding the progression of this policy and hopes to bring it to the Orange County School Board in future months.  As a way to bring addressing youth tobacco and vaping use I offered to be available to facilitate the American Lung Association's INDEPTH and N.O.T (Not On Tobacco) Prevention and Cessation programs to assist students with their cessation attempts.  I also promoted the NC Quitline's Youth Vaping Program as a means of cessation for students. 

Health Equity

Health Equity Council - The Health Equity Council (HEC) recently convened post the COVID-19 pandemic, to resume equity work at the county level. HEC created a results statement and is working to create an environment where “all members of the Orange County community have meaningful access to resources and supports to define, maintain, and improve their physical, mental, and social health and wellbeing.”

One of our Performance Measures is to increase the number of local agencies, in Orange County, who are enrolled in NCCARE360, to help more OC residents and providers become active in the portal.  There are currently 41 OC organizations signed up for NCCARE360 but the number who actively use it is not high enough to report.  This was pre-COVID and we have not made any additional progress since 2021.

Changes in Morbidity and Mortality Data since last CHA

Leading Causes of Death in Orange County (2015-2019)

OC has a lower age-adjusted death rate (per 100,000 people) than NC averages in all ten categories. While OC does not exceed NC in any of the ten categories, OC has experienced a decline in rates among all ten causes of death, since the 2019 CHA, with the exception of slight increases among suicide, Nephritis, Nephrotic Syndrome and Nephrosis, and unintentional injuries.

In Orange County, the top three leading causes of death are cancer, heart disease, and cerebrovascular disease, with trachea, bronchus, and lung cancers being the most commonly experienced cancers.

Emerging Issues

Medicaid Transformation
As of July 1, 2021, most Medicaid beneficiaries began receiving health care services in a new way. With Medicaid Transformation, many recipients transitioned to health plans managed by insurance companies, called Standard Plans, as part of NC Medicaid Managed Care. These plans are managed by a network of providers (doctors, therapists, specialists, hospitals and health care facilities) to address all of a person’s physical health, behavioral health and pharmacy needs. In addition to integrating physical and behavioral health, other program features of the state’s program include establishing a payment structure that rewards better health outcomes, and investing in non-medical interventions that intend to reduce costs and improve the health of beneficiaries.

Some beneficiaries remain in traditional Medicaid, now referred to as NC Medicaid Direct. NC Medicaid Direct includes care coordination from Community Care of North Carolina (CCNC), the primary care case management entity, and via Local Management Entity/Managed Care Organizations (LME/MCOs). North Carolinians with behavioral health, substance use, intellectual and developmental disability (I/DD) or traumatic brain injury (TBI) support needs receive added services through NC Medicaid Direct that are not available through NC Medicaid Managed Care. More information about behavioral health, I/DD or TBI support needs can be found at medicaid.ncdhhs.gov/providers/programs-services/mental-health/behavioral-health-services.
Federally recognized tribal members, or those who qualify for services through Indian Health Service (IHS) and live in Cherokee, Haywood, Graham, Jackson or Swain County, or in a neighboring county of the 5-county region, are able to choose to enroll in the Eastern Band of Cherokee Indians (EBCI) Tribal Option. As a member of the EBCI Tribal Option, beneficiaries are able to receive services from any Medicaid or NC Health Choice provider.

Community Health Workers
The American Public Health Association defines Community Health Workers (CHW) as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.”4
CHW’s provide a number of services to our community, to include neighborhood-level outreach, community engagement, education, connection to area resources, and serve as cultural brokers, systems navigators and advocates. CHW’s work to raise lived narratives and help build trust within the community while informing service delivery and policy improvements. In Orange County, CHW’s have expanded our reach within the community, amplified the voices of the community, and kept us in check and on pulse with the needs of the community.

During and post COVID-19, CHW’s have been serving as an essential support for COVID education, testing and vaccination, and are helping to educate the community on healthy lifestyle behaviors, mental health, parent education, and support to engage with schools, workforce trainings and worksite safety.

New/Discontinued Initiatives

Alliance Health
At the end of 2020, Orange County’s Board of County Commissioners (BOCC) approved moving forward with disengaging from our current LME/MCO, Cardinal Innovations Healthcare, making the decision to begin work with Alliance Health, a managed care organization that manages mental health, traumatic brain injury, substance use and intellectual/developmental disability services. Members of Alliance Health plans are insured by Medicaid or are uninsured.

The BOCC believed that the most effective system for Orange County citizens is to connect with other counties in the Research Triangle, particularly Durham and Wake counties, with the plan to begin services on January 1, 2022. Alliance Health shares Orange County’s goals and priority of “ensuring a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents.

Progress on CHIPs

Health Behaviors 

COVID halted a lot of our efforts and work towards our CHIPs and we were able to begin reengaging the work towards our action plans in 2022.

In relation to the Health Behaviors action plan, where we created the result that "All Orange County" supports safe and responsible use of alcohol".  In working on this mission , our original approach was targeted at:

• Assessing the distribution of on-premise and off-premise alcohol outlets in OC
• Assessing whether local alcohol outlets follow and comply with OC regulated alcohol requirements and laws
• Creating and influencing local ordinances and police to prevent alcohol outlets from being located near youth-related venues.

As we got into the actual work of these action items, we discovered that these goals were more far-fetched than we thought and decided to alter our goals and efforts.  We want to shift our focus and look at the interest around the incorporating social districts in OC, specifically in downtown Chapel Hill.  We want to determine and work with officials on the best practices around the incorporation of social districts and whether or not that would be helpful or hurtful to our county.

We also decided to work to bring all substances together, in the same space, and not work in isolation.  With the increase work, requests and efforts around youth tobacco prevention, specifically related to vaping, we want to work more inclusively.  We plan to utilize the next CHA to determine what other issues, around substance use/abuse, are relevant and trending and obtain additional information in these areas.

Health Equity

The Health Equity Council (HEC) has a strategy to "engage the community to inform the One Orange Racial Equity Index."  Since the development of this strategy, Orange County Government's One Orange committee has undergone various changes.  COVID impacted the overall progress and movement of the development and work with creating the Equity Index, which included working with an outside agency SASS. 

Orange County Government also implemented an organizational change and renamed the Human Rights & Relation Department to the Office of Equity and Inclusion (OE&I), which is where the responsibility of the majority of the One Orange work would live.  The new Office of Equity & Inclusion Director was hired in late 2022 and since then has been working to revitalize One Orange and determine priorities of the group.  The OE&I has had one convening and strategy session to determine priorities and county representatives. 

The Equity Index is one subgroup of One Orange and will begin meeting February 2023.

In relation to "identifying opportunities to vaccinate people of color, historically marginalized and vulnerable populations", we (as a county) are moving past COVID recovery and moving into COVID sustainability.  With state funding coming to an end, targeted COVID testing and vaccination events and locations are ending and will be incorporated into ongoing health clinics and services.  Starting in the spring, the OC Health Department will provide ongoing COVID testing and vaccinations into our medical clinics that patients can obtain during scheduled and walk-in medical appointments and we are supporting partnering agencies/organizations (i.e. Walgreens, Hillsborough Pharmacy, pediatric health, etc.) who are providing COVID vaccinations through their care and services. 

Changes in Morbidity and Mortality Data since last CHA

Aside from COVID-19 and opioids, there are no major changes in morbidity and mortality since the 2019 CHA.

As of March 1, 2023, according to the NC COVID-19 Dashboard, there were 13,596 reported COVID-19 cases last year resulting in 27 deaths in Orange County.  The COVID-19 age-adjusted mortality rate for the 2016-2020 period is 7.4 pe 100,000 for Orange County, compared to 12.8 pr 100,000 for North Carolina.  Among the COVID cases:

• 60% (7,394) of confirmed cases occurred among White residents, who make up 78% of the Orange County population.
• 91% (10,445) of confirmed cases occurred among non-Hispanic residents who make up 91% of the Orange County population.
• 34% (4,607) of confirmed cases occurred among individuals 25-49 years of age, who make up 30% of the Orange County population.
• 18% (2,460) of confirmed cases occurred among individuals 50-64 years of age, who make up 18% of the Orange County population
• 57% (7,737) of confirmed cases occurred among females, who make up 52% of Orange County residents 

As it relates to opioid overdoses and deaths, there were 29 overdose deaths and 110 Emergency Department visits for suspected overdoses in Orange County in 2021, of which more than 90 percent of the deaths were unintentional.

Emerging Issues

Agency and Staff Vacancies 

Orange County Health Department, along with other local, state and national agencies, have experienced a significant change in staff turnover and vacancies.  OCHD currently has a 15% vacancy rate, giving us 22 vacant positions, as of November 2022.

Youth Substance Use

As we continue to investigate substance use and perception of harm among our youth, data shows that Middle school students, in Orange County Schools, have an increased perception of hard to substances (marijuana, tobacco, alcohol and prescription drugs) compared to High School students. 

Our youth are also utilizing areas and farms in Northern Orange County to hold large social gatherings where alcohol and other substances are provided and 

New/Discontinued Initiatives

New Advisory Board 

The Orange County Board of Commissioners (BOCC) approved the creation of the Orange County Opioid Advisory Committee at its Sept. 6 business meeting. The committee will advise the Board of Commissioners on how to utilize the county’s share of the national opioid settlement funds. Orange County is expected to receive $6,799,780 over the next 18 years and has already received its initial payment of $261,245.  This historic $26 billion agreement that would bring desperately needed help to communities harmed by the opioid epidemic.

The committee will discuss opioid-related health concerns and issues impacting Orange County residents, advise the BOCC on options to expend funds to prevent opioid use and remedy opioid impacts, and plan and host an annual meeting to receive input on proposed uses of settlement funds.  The BOCC approved a 19-member advisory committee that includes representatives from the Orange County Sheriff, the Hillsborough, Carrboro and Chapel Hill police departments, Orange County schools, Chapel Hill-Carrboro schools, UNC Hospital, Alliance Health and representatives from the following county departments: Social Services, Emergency Services, Criminal Justice Resource Department and Health.  In addition, several spots will be open for county residents through an application process. Two spots will be for individuals with lived experience, along with a substance abuse treatment provider, a community group working on opioid-related concerns, an employment provider and two flex spots.

Grant Award

Orange Partnership was awarded a new 5-year SAMHSA grant: Strategic Prevention Framework - Parnerships for Success (SPF-PFS Grant) to help increase early intervention for mental health and substance misuse and reduce and prevent youth tobacco and cannabis use. This grant was competitive and awarded to only 15 participants across the county.  This grant will provide financial support for the coalition's new priorities centered on mental health and reducing youth use of nicotine and cannabis use. Some of this work has already begun, such as the collaboration between OCHD, Insight and Safe Kids to address the vaping epidemic in Orange County Schools. We are working toward increasing resources such as cessation programs, professional development (Mental Health First Aid/Suicide Ideation Screenings, Tobacco Treatment Training, Results Based Accountability Training, Drug Impaired Training for Educational Professionals, Media Literacy training, etc.). Coalition members who have already provided letters of committee shared some of the work they will be doing to effect change. Below are the areas that we believe are protective factors to help improve mental wellbeing and help reduce the likelihood of youth substance use as well as the risk factors that might lead to youth substance use and poor mental health.

Community Engagement

Orange County Schools recently created a Parent Academy, every spring and fall, to help educate parents more on the issues of their youth.  The academy is around multiple topics where parents can choose when they want to attend, based on the topic being discussed.   Parent Academy is held on Wednesday evenings. There were 12 participants in the Fall session.

Chapel Hill Carrboro City Schools has a Family Engagement Department, which recently hired a new Family Engagement Director in June 2022.  They have been working with the OCHD to help train and educate staff on the various tobacco outlets that they should be aware of to include Delta 8, vaping, etc.  In anticipation of a healthy and safe holiday season, CHCCS announced the roll-out of their Family Alcohol Education Campaign designed to facilitate productive conversations about alcohol between families and students. The harmful consequences of underage drinking have long-lasting impacts, but underage drinking is preventable. With your critical help, we can support the health and well-being of our students.

The Gateway Collaborative

The Gateway Collaborative was created and is comprised of individuals from local government and residents from the Gateway community.  Multiple individuals from local government agencies rotate to serve as representatives from the Orange County Health Department, the Orange County Department of Social Services, Orange County Housing & Community Development and the Office of Equity and Inclusion.  As a collaborative, we are working to demonstrate recurring patterns that act as a guide for the Gateway Initiative to help make decisions based on specific themes of interest.  The Collaborative is working to identify and improve metrics around housing stability, health outcomes, finalcial stability, tenant safety, access to services and education. 

OC Health Department and OC Department of Social Services jointly rent an apartment at the Gateway Village housing community to serve as a community resource center.  In addition to the previously mentioned departments, the school system and law enforcement are members of the collaborative.  The Collaborative works with the residents to identify priority issues to garner resources for the priority areas. 

Accreditation 

The Orange County Health Department completed its 2023 Accreditation process and Site Visit in January, 2023 where the NCLHDA Site Visit Team was able to designate 146 activities out of 147 as ‘Met’ by the Orange County Health Department. Scoring for Reaccreditation requires that each activity be scored individually and that the Health Department must satisfy at least a minimum for each core function and essential service. A Health Department is designated as Reaccredited with Honors if they miss one or less activities within each
of the core functions/essential service standards.

The NCLHDA Site Visit Team recommends the Orange County Health Department for Reaccreditation with Honors.