Gaining access to good health care - particularly in rural communities - is the top priority for residents of five Central Missouri counties.
That was the finding of the 2018 Community Health Needs Assessment, done every three years as a requirement of the Affordable Care Act.
A collaboration of stakeholders - including Capital Region Medical Center; St. Mary's Hospital; health departments from Cole, Callaway, Miller, Moniteau and Osage counties; the Community Health Center of Central Missouri; and the United Way of Central Missouri - conducted the assessment to help plan strategies intended to improve the health of the region.
The collaborators on the assessment conducted surveys and held multiple public input meetings throughout the region to gain an understanding of residents' deepest health care concerns.
Priority 1: Access to health care
Surveys asked respondents about their lifestyles, education and demographics. They asked about diets and habits, what their health problems were, and how accessible care was.
What came to the surface was the complexity of providing health care for a region, according to Bev Stafford of St. Mary's Hospital in Jefferson City.
Although "access to health care" rose as the top priority for 2018, it's not a simple need to define.
"The ability to access care is influenced by many factors, including insurance coverage and the ability to afford services, long waits for appointments or treatments, the availability and hours of operation of health care providers, an understanding of where to find services when needed, a lack of providers accepting new Medicaid patients and a lack of reliable personal or public transportation were frequently mentioned as concerns," according to the assessment report.
"Health and well-being have taken on a new meaning for communities, and it is complex," Stafford said. "Systems of care - and not just conditions of disease and illness. Folks are listening differently. Folks are able to articulate it differently."
They're seeing that sometimes socioeconomic status or social determinants of health are sometimes greater risk factors for health than smoking.
The priorities have changed substantially since the previous assessment, Stafford said. But so has the research.
Surveys are now intended to look not only at the most obvious health concerns, but the underlying causes of concerns - whether socioeconomic, physiological or sociological.
"There is an evolution of this," Stafford said. "Six, nine, 10 years ago, we were talking about tobacco cessation as a priority."
As a key risk factor, it's a major risk factor to the conditions that are most prevalent in the community - cancer, diabetes and heart disease.
But there are many more factors involved in determining the health of the community.
"There has been an evolution - even within our own health care institutions, community partners and health and human services agencies," Stafford said.
They are looking at things differently and wondering how they can solve issues, of which their "silos" are only touching the edges.
The last health assessment the region had done prior to passage of the Affordable Care Act occurred in 1999.
In 2012, the first assessment after the ACA passed found in general terms the priorities were access to care, heart disease, obesity, access to cancer screenings or prevention, diabetes prevention and management, and the general health status of Miller County.
The deeper delve into the underlying issues affecting Mid-Missouri health came about during the second assessment. In 2015, when the coalition, known as the Central Missouri Community Health Assessment Partnership, dug deeper, the community's priority was heart disease or obesity, followed by mental health services, access to care and health literacy, substance abuse, and adult oral health.
Rather than each agency or nonprofit focusing on addressing individual issues associated with the health of the community, the assessment gives them all a better chance to work together to improve overall health.
"At one of the community input sessions, one of the elected officials said, 'Wow, wouldn't it be great to use this as a health policy road map for those things that we need to really focus on to improve the health and well-being of the communities we represent?' That's an evolution of what this process - of what a community health assessment - can mean to a community," Stafford said.
Priority 2: Mental health
Mental health disorders and substance abuse ranked second on this year's priority list. In 2016, although they didn't see concerns about mental health care as much in their surveys, members of the partnership heard anecdotes about the need for that specific health care, according to Cole County Health Department Director Kristi Campbell.
"We heard there is a lot of need for mental health care, especially for small children," Campbell said.
Community discussion group participants and steering team members shared concerns about mental health issues in Central Missouri. Anxiety, depression and the risk of suicides were prevalent concerns, according to the report.
The problems are compounded by concerns over social stigmas, limited numbers of mental health providers and facilities in the area, long wait times for treatment, and failures to treat physical health issues.
Of note, the report states, "was the gap in providers for youth and families in distress."
The county does not provide mental health care, Campbell said. However, when it goes to schools, it tries to emphasize healthy relationships.
"(Those relationships) reflect throughout a child's life and in every aspect of their life," she said.
Members of the partnership are discussing how best to overcome issues, Stafford said. They have to identify the right people - with the right resources - to come to the table and work to provide treatment or prevention.
"The United Way, being part of our partnership and educating their boards, committees and councils, is having a more purposeful conversation around mental health," Stafford said. "And priority funding - or maybe allocation of dollars that support the community differently or more purposely - around mental health."
Ann Bax, president of the United Way of Central Missouri, said behavioral health care is a critical need. She and other United Way staff members attended discussion sessions in communities for the assessment.
"This is a huge, huge issue," Bax said. "We're talking a lot about it. We're starting to put more revenue toward it."
On Friday, the United Way announced the availability of $197,334 in Community Support Grants. The grants are offered to agencies beyond the 25 the organization already supports and are supplied from revenue that is generated beyond the United Way's annual fundraising goal. This year, the agency surpassed its $2 million goal by more than $200,000.
In 2019, the agency's grants will put a priority on programs focused on mental health issues, Bax said.
No one entity can resolve underlying mental health issues that affect overall health in Central Missouri, she said.
The United Way is in a unique position where it sees what services nonprofit organizations are providing to the community. It is working with Compass Health - whose expertise lies in mental health - to identify programs they might bring to the community, Bax said.
"We can hopefully be a mobilizer," she continued. "We've got some money carved out. We don't yet know what we're going to do with it.
"(Mental health issues are) affecting every need in the community today."
Priority 3: Chronic diseases
Diabetes, heart/cardiovascular disease, lung cancer and chronic obstructive pulmonary disease, were among the chronic diseases named as the third highest priority in the 2018 study. Those diseases and their prevention are leading causes of death in the region.
Among surveys and discussion groups, diabetes and heart disease were the most frequently mentioned chronic diseases - and often were linked into discussions about obesity.
"The age-adjusted death rate (from heart disease) per 100,000 population is 186.8 for the five-county report area," according to the report. That is more than twice the statewide rate of 85.6 per 100,000.
Age-adjusting rates is a way to make fairer comparisons between groups with different age distributions, according to the Missouri Department of Health and Senior Services website.
Tiffany Rutledge, community coordinator for Capital Region Medical Center in Jefferson City, said that - as with the other health issues the assessment identified - there are multiple underlying factors affecting chronic diseases and health risks in Central Missouri.
Youth have access to electronic smoking devices, but that's just a piece of the problem.
Poverty and the lack of affordability and availability of nutrient-dense foods play roles in obesity. Sedentary lifestyles are more common, she said.
"There are a lot of programs that have been put in place to help educate, but as you can see, health literacy is still one of our needs," Rutledge said. "There's a mentality that 'My grandpa had high blood pressure, my dad had high blood pressure, I have high blood pressure it's just in my genes.' Science says we can turn off those markers."
You cannot address chronic diseases, such as diabetes, heart disease, lung disease and other chronic conditions, without addressing obesity, physical inactivity and tobacco use, Stafford said.
People don't have time in their schedules to address some of these issues.
"We're not just short on money," Rutledge said. "We're time poor. People just don't have time in their schedules to prepare healthy meals."
Fast-food restaurants are going to win out about every time, she said.