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Central New Hampshire Health Partnership Community Health Needs Assessment 2011

Central New Hampshire Health Partnership Community Health Needs Assessment 2011

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Published by Arielle Slam
A 2011 community health needs assessment of the Greater Plymouth and Newfound area of New Hampshire.
A 2011 community health needs assessment of the Greater Plymouth and Newfound area of New Hampshire.

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Published by: Arielle Slam on Oct 28, 2011
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PARTNERS

Communities for Alcohol and Drug-Free Youth  Community Action Program, Belknap-Merrimack Counties Genesis Behavioral Health  Mid-State Health Center  Newfound Area Nursing Association Pemi-Baker Community Health  Plymouth Pediatrics and Adolescent Medicine Plymouth Regional Clinic  Speare Memorial Hospital www.cnhhp.org

With technical assistance provided by Arielle Slam and Jonathan Stewart NH Community Health Institute

Central NH Health Partnership Community Health Needs Assessment

2011

Central NH Health Partnership Service Area

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Central NH Health Partnership Community Health Needs Assessment

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Central NH Health Partnership Community Health Needs Assessment

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Table of Contents
Executive Summary…………………………………………………………………………………1 Section A: Secondary Data Collection……………………………………………………15 Section B: Community Survey Summary & Analysis ……………………………37 Section C: Conversations with the Community ……………………………………51 Appendix I: Community Survey Results Appendix II: Parent Focus Group Notes Appendix III: Service Providers Focus Group Notes Appendix IV: Faith Leaders Focus Group Notes Appendix V: Focus Group Facilitator Script Appendix VI: Community Leader Interview Script Appendix VII: Sample Community Survey Appendix VIII: Towns By Geography
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Central NH Health Partnership Community Health Needs Assessment Executive Summary

2011

The 2011 Community Health Needs Assessment report is the most recent effort by the Central New Hampshire Health Partnership to provide residents of the Greater Plymouth and Newfound region with a comprehensive summary of the health of the area’s population. The specific aim of this report is to:     Describe the current health status of the Greater Plymouth and Newfound population; Summarize potential risks to the population’s future health; Identify community health needs, priorities and aspirations from the perspective of area residents; and Provide information to support collaboration among individuals, communities and the health care delivery and public health systems to assure the future health of the region’s population.

Overall, New Hampshire is a healthy state. In 2010, New Hampshire was ranked as the third healthiest state in the nation and is consistently among the top 10 healthiest states according to a commonly cited source of annual state health rankings.1 The Greater Plymouth and Newfound region is similar to the State overall on many measures of health and well-being. Information from community conversations and surveys included in this report further confirm that area residents enjoy a high quality of life marked by appreciation of the natural environment, low rates of crime, and a strong sense of community. However, information included in this report also indicates that there remains work to be done to meet the region’s potential for assuring the health and well-being of all area residents. Although most residents are healthy and live relatively comfortable lives, the current health and well-being of some area residents is not as good as it could be. Some residents are disabled by chronic disease, some have limited or no access to routine health care through health insurance, some live in poverty, and some die prematurely from preventable conditions. Additionally, many residents engage in unhealthy life-style behaviors, behaviors that can be linked to chronic diseases, injury and even death in the future.

Broad Definition of Health and a Model of Health Determinants
The definition of health used to frame this report was proposed by the Institute of Medicine2. In this definition, health is defined as “a state of well-being and the capacity to function in the face of changing circumstances.” This definition of health implies that “health” is the outcome of a mix of many factors that interact at the individual, community, and societal level. Also, “health” encompasses both the concept of “well-being” (health defined by the individual) as well as the concept of “absence of illness and disease” (health defined by the medical system).

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One model for visualizing how a community or society may act on this definition of health is the Field Model of Health and Well-Being.3 As depicted by the illustration below, the domains of Health and Well-Being are impacted by a number of inter-related factors. These include individual choices and behaviors, as well as actions through the health care delivery system to promote health and prevent disease and injury. At a broader societal level however, each of these are in turn influenced by factors such as education and income levels, the physical and social conditions in which people live including resources and policies that promote health, as well as social norms that influence healthy lifestyles. The potential for interactions between these domains suggests a role for everyone, from the individual, to the family, to the organizational and community levels, in producing improved health and well-being for all residents of the Greater Plymouth and Newfound region of New Hampshire.

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Primary Sources of Data and Methods
The Central New Hampshire Health Partnership (CNHHP) used three primary methods for gathering information on community health needs. Quantitative data were used to summarize aspects of health and well-being for the population. Sources of data included the New Hampshire Behavioral Risk Factor Surveillance System (BRFSS), the New Hampshire Youth Risk Behavior Surveillance System (YRBSS), NH Vital Records Administration and NH Hospital Discharge Data. Statistics were also collected from national sources, including the United States Census and the American Community Survey. A community needs survey was also distributed throughout the CNHHP service area from March through June 2011. Survey respondents were asked to consider a number of health-related issues, health care and community health needs, and were provided an opportunity to comment on what they would do to make their community a healthier place. The survey was distributed using online links and email blasts, display stands, asking front desk staff to prompt visitors to complete the survey, and asking people to complete the survey outside of the Bristol Shop & Save. A total of 600 completed surveys were returned; representing about 2.2% of the entire adult population in the service area. Finally, a series of community conversations were held to provide richness and nuance and to validate the quantitative data collected through secondary sources and the community survey. These conversations included 22 community leader interviews and 3 focus groups. Community leaders were defined as residents of the service area that also play key roles in health care or social service delivery, or work in sectors that impact the community’s risk and resiliency factors. Focus groups were conducted with a group of human service providers, parents participating in a parent education group, and a group of faith community leaders.

Key Findings and Observations
1. Growing and Aging Population: The total population of the 21 towns comprising the Greater Plymouth and Newfound region has grown by nearly 15% in the past 10 years to over 35,000 people. This rate of growth is higher than the statewide population growth of 6.5% over the same time period. Most of the increase in population has occurred among residents who are 50 years of age and older (net increase of 4,543 residents), while the total number of residents under 50 has declined slightly (net decrease of 82 residents). This trend has significant implications for the demand and capacity for health and human services to serve a growing and aging population in the region.

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2. Income and Insurance: As illustrated by the Field Model of Health and Well-Being, prosperity can directly influence well-being, as well as the social and physical environmental determinants of health. While New Hampshire is a relatively prosperous state overall, the median household income in the Greater Plymouth and Newfound region lags behind the State median by 24%. As also indicated by the table below, about 11% of service area residents live in poverty with household incomes less than 100% of the federal poverty level (FPL) and nearly 30% of service area residents are considered low-income (< 200% of the FPL) compared with 20% of the state’s residents overall.
Indicator Population below federal poverty level (FPL) Population below 200% of FPL Median Household Income (2009) No health insurance CNHHP Service Area 10.6% 29.7% $46,218 18.3% NH Overall 7.7% 20.0% $60,734 10.8%

Income and employment influence the availability and affordability of health insurance. The rate of uninsurance is also significantly higher in the region than for the state overall. A common theme raised in the community conversations was that there are disparities in the region where people with health insurance have sufficient access to high quality health services, while those without insurance and with limited means struggle to achieve the same level of access and an associated level of health and well-being. In the community survey, “Job Opportunities” was the number one characteristic selected by respondents (56%) that should be focused on to support community health improvement. 3. Access to Services: All 21 of the towns in the region are included in areas designated by the federal government as Health Professional Shortage areas or Medically Underserved Populations. In spite of this level of designation, nearly 90% of adults in the region have indicated that they do have a regular primary care provider. However, 17% of the area’s adults also noted they were unable to see a doctor when they needed to because of cost compared with only 11% of adults statewide who reported this circumstance. Respondents to the community survey were also asked whether, in the past year, they or someone in their family had difficulty getting the services they needed.
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About 44% of respondents selected “yes”, they had experienced difficulty accessing services. When asked to specify further, the top 3 services with access difficulties reported by survey respondents were as follows: 1. 2. 3. Dental care for adults Primary health care Mental health 23.5% of all survey respondents 18.0% 10.5%

Respondents reporting difficulty accessing services were also asked why it was difficult to access the services they needed. The top reasons cited were as follows: 1. 2. 3. Could not afford to pay Had no health insurance Service I needed was not available 24.7% of all survey respondents 21.8% 13.0%

4. Availability of Dental Care: As noted above, dental care for adults was cited most frequently by community survey respondents as the service type for which they had experienced difficulty getting the services they needed. About 6% of respondents also reported difficulty accessing dental care for children. When asked to identify the “most pressing health issue” in the community, about 50% of respondents selected “access to dental health care”; exceeding the next highest rated issue - “access to enough health insurance” (39%) – by a substantial margin. The limited availability of dental care was also a common theme in the community conversations and it was noted in particular that there are currently no dentists located in the Newfound area. About 25% of adults in the Greater Plymouth region (not including the Newfound area) reported on the statewide Behavioral Risk Factor Survey that they had not had dental visit in the past year; a rate similar to the statewide rate. 5. Transportation: The lack of transportation in the region was also a common theme of the community health needs assessment. As implied by the Field Model of Health and Well-Being, residents with limited transportation options may also experience difficulty in accessing services and participating in aspects of community life that contribute to individual and family health and wellbeing. In our community survey, about 51% of respondents identified “public transportation” as a service or resource that should be focused on for improvement to support a healthy community; second only to improved job opportunities (56% of respondents). Similarly, when asked in an openended question to identify the most difficult aspect of living in their community, the top difficulty mentioned (18% of all respondents) was the lack of transportation including lack of public transportation. Related issues of long travel distances to services and activities, as well as the associated costs of transportation were also cited by 13% of respondents as the most difficult aspect of living in the Greater Plymouth and Newfound region.
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6. Chronic Disease: In the Greater Plymouth region, 7.1% of all hospital discharges are for chronic conditions that could be amenable to primary care such as diabetes and asthma. This rate is statistically different and higher than the overall state rate (6.4% of hospital discharges). The percentage of adults in the Greater Plymouth public health network service area who have ever been told they have diabetes (9.4%) is slightly higher, but statistically similar to the state (7.2%) and national percentages (8.4%). However, the burden of morbidity and mortality from diabetes is also high in the service area. Compared with a national rate of 25.1 deaths per 100,000 people with diabetes as an underlying cause, over 58 per 100,000 service area residents die with diabetes listed as an underlying cause. Similarly, rates of adult asthma are slightly higher, although not statistically different, in the Greater Plymouth public health region compared to the state with nearly 12% of adults reporting a current asthma diagnosis. It is important to also note that, according to the 2011 New Hampshire State Health Profile, NH has among the highest rates of asthma in the nation with 10.2% of adults who currently have asthma. As the state report notes, “Among the possible reasons for poor asthma control are inadequate insurance coverage, including coverage for drugs, limited access to primary care providers…” These are characteristics that describe the Greater Plymouth and Newfound region as previously noted. Further evidence of the burden of asthma in the region is the relatively high rate of asthma-related hospital discharges (99.7 discharges per 100,000 population compared with a statewide rate of 80.0). 7. Behavioral Health and Substance Abuse: While access to dental care was identified in the community survey as the most pressing health issue in the community, respondents also frequently selected several factors associated with behavioral health including alcohol & drug use (38% of survey respondents), access to mental health care (34%), youth alcohol & drug use (34%) and mental illness (34%). Community members and leaders similarly described limitations in the capacity of existing mental health and substance abuse treatment services and suggested a need for additional mental health services such as psychiatrists, licensed alcohol and drug counselors, emergency mental and substance use treatment services, and outpatient mental and addiction services. As displayed by the following table, inpatient and emergency department discharges for mental health and substance abuse-related conditions are similar or lower than for the state overall. This suggests that the perceived problems in the region regarding the prevalence of mental health and substance abuse conditions and insufficient service capacity to address these issues are equally severe across the state.

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Indicator Mental Health Condition Inpatient Discharges per 100,000 People; age adjusted Substance Abuse-Related Mental Health Condition Inpatient Discharges per 100,000 People; age adjusted Substance Abuse-Related Emergency Department Visits per 100,000 People; age adjusted Mental Health Condition Emergency Department Discharges per 100,000 People; age adjusted

Greater Plymouth Region

NH Overall

Statistical Significance

376.0 427.7 543.4 1252.9

484.6 438.2 683.1 1368.7

Lower Similar Lower Lower

8. Healthy Eating and Active Living: Similar to diabetes, changing lifestyles have spurred a nationwide increase in the number of overweight and obese adults. In the Greater Plymouth Public Health Region, about 58% of adults are overweight or obese. This rate is similar to the statewide rate of 63% of adults who are overweight or obese. While the community conversations found a perceived lack of indoor exercise facilities in the area, it is interesting to note that area residents exceed the percentage of adults statewide who regularly engage in moderate or vigorous physical activity (65% region; 54% state). Lack of good nutrition and nutrition education was the other major factor identified by community leaders as a cause for the increasing overweight and obese population and was identified as a pressing health issue by 35% of the community survey respondents. Additionally, a fitness/exercise program was the most commonly selected type of service or program that they would use if more available in the community (49% of respondents). The community survey also asked residents the following question: “If you could change any one thing that you believe would contribute to better health in your community, what would you change?” This question prompted a range of opinions and thoughtful suggestions, but the most common theme (11% of respondents) can be categorized as “Healthier Eating, Active Living”. This category included a variety of suggestions for community health improvement through a focus on improving food choices, including food served in schools, and increasing community resources to promote indoor and outdoor exercise.

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It is the hope of the Central New Hampshire Health Partnership that the information contained in this report will assist residents, area organizations, community groups, and municipalities to better understand the community health needs in our region and to identify ways we can work together to address some of these needs. All of us can participate in activities that benefit and strengthen our community. Agencies may use the information in this report to prioritize available resources. Community members may join with others to develop strategies and actions for addressing significant needs, or as individuals we may choose to help neighbors by volunteering time and expertise to help meet an identified need. Thank you to everyone who participated in this assessment as well as to those who will work toward improvement of our community’s health and well-being.

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Section A Secondary Data Collection

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Central NH Health Partnership Community Health Needs Assessment Secondary Data Collection & Analysis

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Methodology: Quantitative data were used to summarize aspects of health and well-being for the population. The data were collected from national sources, including the US Census (2000 & 2010) and the American Community Survey (2005-2009 5 year estimates). Data for this report was also drawn from state sources including the New Hampshire Behavioral Risk Factor Surveillance System (BRFSS), the New Hampshire Youth Risk Behavior Surveillance System (YRBSS), NH Vital Records Administration and NH Hospital Discharge Data. Additional, state and local publications are referenced. Where available, data specific to the Central NH Health Partnership (CNHHP) service area are provided. Towns included in the service area are: Alexandria, Ashland, Bridgewater, Bristol, Campton, Danbury, Dorchester, Ellsworth, Grafton, Groton, Hebron, Holderness, Lincoln, New Hampton, Orange, Plymouth, Rumney, Thornton, Warren, Waterville Valley, Wentworth, and Woodstock. For indicators that did not have town level data, information for the next closet geographic area was used, such as for the Greater Plymouth Public Health Region or Grafton County overall.. To see population and towns by service area, public health region, and county see Appendix VIII. Some terminology used in this assessment includes the following. Prevalence is defined as the total number of cases of a disease or risk factor in the population at a given point in time. Incidence describes the number of new cases or events over a certain period of time, such as the annual mortality rate. Mortality is used to describe death overall or as a result of a certain type of disease or injury. The data may be presented as a crude count, but is most commonly shared as a rate or percentage of the population. A rate is typically expressed as the number of events per 1,000, 10,000 or 100,000 people. Some rates are age-adjusted, which allows for comparison between populations with different age distributions. The researchers are thankful to the New Hampshire Department of Health and Human Services, Office of Health Statistics and Data Management and NH HealthWRQS for their data and technical assistance to this project.

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Demographics: The service area is comprised of 21 towns of varying populations and characteristics, ranging from the most densely and largely populated town of Plymouth (pop. 6990) to Ellsworth with a population of 83. Figure 1 shows the population for each town in the service area by age group. Ninety-nine percent of service area residents are of one race, 97.7% of those being white while Asians make up the next highest single race group at 0.82%.4 Gender distribution is nearly equal with 49% female and 51% male 5
Figure 1. CNHHP Service Area 2010 Population By Town Total Pop
1613 2076 1083 3054 3333 1164 355 83 1340 593 602 2108 1662 2165 331 6990 1480 2490 247 911 1374 35054

Towns
Alexandria Ashland Bridgewater Bristol Campton Danbury Dorchester Ellsworth Grafton Groton Hebron Holderness Lincoln New Hampton Orange Plymouth Rumney Thornton Waterville Valley Wentworth Woodstock CNHHP Total

Under 5 years
4.6% 5.6% 4.8% 6.1% 4.8% 4.6% 2.3% 3.6% 4.7% 4.7% 3.7% 3.7% 4.0% 5.9% 4.2% 2.8% 4.3% 4.9% 0.4% 4.9% 4.1% 4.4%

5 to 19 years
17.7% 14.0% 14.1% 17.4% 17.4% 18.0% 16.6% 15.7% 15.5% 14.0% 14.1% 18.0% 16.1% 18.7% 21.1% 28.0% 19.1% 15.5% 17.4% 14.9% 17.7% 19.0%

20 to 24 years
5.4% 7.9% 3.8% 5.1% 4.9% 3.6% 3.9% 1.2% 4.9% 3.0% 2.7% 6.3% 5.4% 3.2% 4.5% 31.7% 4.9% 4.4% 3.6% 5.5% 5.3% 10.3%

25 to 34 years
9.7% 13.1% 7.3% 11.1% 11.2% 11.6% 8.5% 9.6% 9.9% 9.4% 7.5% 7.4% 8.9% 11.0% 7.3% 6.6% 8.8% 9.8% 2.8% 10.8% 10.5% 9.3%

35 to 49 years
22.9% 20.0% 21.5% 20.6% 21.7% 21.6% 21.7% 19.3% 23.3% 21.2% 14.0% 19.9% 18.1% 22.7% 25.7% 10.8% 19.0% 24.2% 14.2% 19.2% 22.8% 19.1%

50 to 64 years
25.9% 22.6% 26.2% 24.2% 25.7% 27.1% 33.5% 22.9% 27.1% 28.3% 30.2% 26.3% 27.1% 23.0% 23.6% 12.2% 26.6% 27.0% 34.8% 24.8% 23.1% 23.0%

65 to 74 years
9.0% 8.9% 13.1% 9.4% 8.9% 8.2% 7.0% 24.1% 9.4% 12.0% 15.9% 10.9% 12.0% 9.0% 9.4% 4.2% 8.7% 9.1% 21.5% 13.3% 10.3% 8.9%

75 and older
4.8% 7.9% 9.1% 6.1% 5.5% 5.2% 6.5% 3.6% 5.1% 7.3% 12.0% 7.5% 8.4% 6.5% 4.2% 3.8% 8.6% 5.1% 5.3% 6.6% 6.1% 6.0%

Median age (years)
44.6 43.1 49.2 43.5 44.1 44 49 50.5 45.6 48.5 55.1 46.9 48.5 42.4 42.9 21.7 45.9 45.5 55.3 47.3 44.2

US Census, 2010

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The total population of the service area has grown by nearly 15% in the past 10 years, with 7% of that growth occurring in the last three years. This is higher than the statewide population growth since 2000 of 6.5%. 6 7Older adults account for the largest proportion of this increase with nearly all of the growth among residents 50 years and older. The only other age group to show positive growth is 20-24, which may be representative of growth in the student body at Plymouth State University.
Figure 2. CNHHP Service Area Population Growth by Age Ages Under 5 years 5 to 19 years 20 to 24 years 25 to 34 years 35 to 49 years 50 to 64 years 65 to 74 years 75 and older Service Area Total NH Total 2000 Population 1545 6913 2740 3437 7217 4967 2182 1592 28107 1,235,786 2010 Population
1535 6667 3601 3273 6694 8067 3104 2113

% of Total in 2010
4.38% 19.02% 10.27% 9.34% 19.10% 23.01% 8.85% 6.03%

Growth 2000-2010 -0.65% -3.56% 31.42% -4.77% -7.25% 62.41% 42.25% 32.73% 14.58% 6.5%

35054 1,316,470

US Census Data, 2000 & 2010

Socioeconomic Indicators
Poverty: Over 10% of service area residents live in poverty with household incomes less than 100% of the federal poverty level (FPL). Nearly 30% of service area residents, as opposed to 20% of New Hampshire residents overall, are considered low-income (< 200% of the FPL). Income & Insurance: High unemployment in the service and retail sector, seasonal tourism and other small business employers, leave many individuals and families completely uninsured. In 2010, state unemployment was at 6.1% and Grafton County unemployment was at 4.9%.8 The median household income in the service area is only about 76% of that of the State overall. Only two towns in the region (Waterville Valley and Ellsworth) exceed the statewide median household income, and several towns including Ashland, Bristol and Lincoln have a median household incomes of about 60% or less of that of New Hampshire overall.9
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Figure 3 shows that the estimated proportion of the service area without health insurance (18.3%) is significantly higher than the overall state rate and is also higher than the national rate (15.5% uninsured, US Census Bureau, 2010).
Figure 3. Service Area Economic Indicators

Indicator Population below federal poverty leveli Population below 200% of federal poverty leveli Median Household Incomei No health insurance

CNHHP Service Area 10.6% 29.7% $46,218 18.3%ii

NH Overall 7.7% 20% $60,734 10.8%iii

i. American Community Survey, 2005-2009 ii. Estimate based on total population (Census 2010) under 200% poverty in service area (ACS 05-09) less total Medicaid population in service area(NH Medicaid Annual Report, FY10) iii. 2011 NH Regional Health Profiles, NH DHHS, Division of Public Health Services, 2008-2009 data

Access to Care: The service area is comprised principally of communities with underserved/shortage area designations reflecting limited access to primary care professionals and related health services. All 21 of the service area towns are designated as Health Professional Shortage areas, Medically Underserved Populations, or both. In the service area:     Nineteen of the 21 service area towns are federally designated Medically Underserved Populations (MUPs). Seventeen of the towns are designated as Health Professional Shortage Areas (HPSAs) Eighteen of the towns are included in a mental health HPSA Twelve of the towns are included in a low-income Dental HPSA

As a critical access hospital, Speare Memorial Hospital serves the vast majority of residents from the service area. Even residents from the Newfound area that may be geographically closer to hospitals in Franklin/Laconia, receive the majority of their hospital care at Speare Memorial Hospital.10 Nearly 90% (89.7%) of adults in the public health region have indicated that they have a primary care provider; however, 17% of the area’s adults noted they were unable to see a doctor when they needed to because of the cost compared with only 11% statewide.11 Twenty-five percent of Grafton County adults report they did not have a dental health visit in the past year and 74.8% reported having a dental visit in the past year. Nationally, 56.69% of adults go without a dental visit in a year.12

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Figure 4. Access to Care 13
Indicator Greater Plymouth Public Health Region

2011

New Hampshire

Have primary care provider, percent of all adults No health insurance, percent of all adults Unable to see a doctor when needed due to cost, percent of all adults Did not have a dental health visit in the past year, percent of all adults Acute ambulatory care sensitive condition hospital discharges, percent of all discharges Chronic ambulatory care sensitive condition hospitals discharges, percent of all discharges Substance abuse-related emergency hospital discharges Mammogram in past two years, percent of all women age 40 and older Colonoscopy or sigmoidoscopy in past 5 years, percent of adults age 50 and older Pap test in past 3 years, percent of women age 18 and older Cholesterol tested past 5 years, percent of adults

89.7 18.3 17.1 25.2

88.9 10.8 10.9 24

Preventable Hospitalizations 6.9 7.2

7.1

6.4

35.9

32.1

Preventive Screenings 71.4 81.0

52.4

58.2

84.1 78.2

87.1 81.9

Only indicators in red are statistically significant differences from the state rate/percentage.

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Education: An individual’s educational attainment is positively correlated with better health outcomes and therefore is a relevant indicator of a population’s health status. Across age groups, service area residents lag behind the state in achievement of undergraduate and advanced degrees.14 While newer generations of residents in the services area are reaching higher levels of educational attainment than older residents, the majority of the adult population in the area does not have a college degree.    Fifty-eight percent (58%) of adults 25-34 in the service area have had education beyond high school or the GED versus 66% statewide. Among 25-34 year olds, 36% of males and 33% of females hold high school degrees or GEDs as their highest level of academic achievement. Females continue to not only bridge but to exceed the gap between sexes in educational achievement. In fact, 33% of females 25-34 years old have Bachelor’s degree, while only 21.29% of their male counterparts have achieved the same level..15

Family structure: Perhaps indicative of the large population of older adults in the service area, the vast majority of households (72%) have no children living with them (figure 5). The ratio of married w/children households, single family households, and childless households is comparable statewide and nationally (figure 6). Among households with children (regardless of paternity), 66% (2314) of the households include a married couple. 16

Figure 5. Household Composition in Service Area, 05-09
Married-couple family with children under 18 years present

19% 6% 72%

3%
Male householder with no wife present and children present under 18 yrs Female householder with no husband present and children present under 18 years Households with no people under 18 years

Data Source: 2005-2009 American Community Survey, 5 year estimates

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Figure 6. Household Structure Comparison
80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% United States (%) New Hampshire (%) Service Area (%)

Married-couple Male householder Female householder Households with no family with children with no wife present with no husband people under 18 under 18 years and children present present and children years present under 18 yrs present under 18 years

Data Source: 05-09 ACS

Death Indicators
Premature death, or death under the age of 65, is high in the area with a rate of 218.3 premature deaths per 100,000.17 This is of particular concern (and statistically significant) when compared with the State rate of 180.1. Premature mortality is highest among 55-64 year olds in the region (926.3 in the service area versus 727.7 in the state).18 Death from chronic lower respiratory disease (emphysema & bronchitis), a disease primarily caused by cigarette smoking, is particularly high among this age group in the region (85.7 in Greater Plymouth Public Health Region versus 40.6 statewide). However, the total number of events is small, which negates any statistical significance.19 As the 2011 State Health Profile reports, eight of the top 10 causes of death in the state and the service area are related to individuals’ modifiable lifestyle and behavior.20 Cancer is a leading cause of death in the service area (192.5) and statewide (193.1), although the rate is still below the national rate of 196.1.21 When adjusted for age distribution across geographies, the rates again are comparable with the public health region at 173.1 and the state at185, respectively.22 Total cancer incidence rates (500 per 100,000) are also comparable to the state (495.2) and the nation (458.7).23 Again, when age-adjusted cancer rates remain comparable between the region and the state.24 The only leading cause of death in the area to exceed state rates is accidents, specifically among 4554 year olds. Regionally, the rate of unintentional injury deaths for this age group is 64.4 while statewide it is only 31.7.25 Suicide deaths in the area match the state rate: at 11.5 per 100,000.26

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Figure 7. Overall Leading Causes of Death (rate per 100,000)
Leading Causes Cancer Heart Disease Chronic lower respiratory diseases (including emphysema & bronchitis) Accidents Stroke Alzheimer’s Disease Influenza and pneumonia Suicide Diabetes Chronic liver disease and cirrhosis Service Area 192.5 183.6 39.8 37.6 23.2 19.9 12.2 11.1 11.1 11.1 NH State 193.1 189.3 46.3 36.7 37.2 29.4 17.3 11.8 22.3 x

NH Division of Vital Records Administration Death Certificate Data, 05-07 missing towns: Groton, Hebron, Lincoln, Waterville Valley, Wentworth

Prenatal
Infants born with a low birth weight are at a higher risk of infant mortality and of long-term health issues than babies born at a normal weight.27 At less than 5%, the proportion of low birth weight infants in the region is slightly lower, although statistically similar to the state and nation (4.8% CNHHP, 6.5% NH, 6% US).28 Women who smoke during pregnancy are more likely to give birth prematurely, have complications in birth, and give birth to a low-birth weight baby.29 Therefore, it is of concern that cigarette use during pregnancy is higher in the service area (18.2%) than nationally (10-12%), although the service area rate is similar to the state rate (16.4%) for this indicator.30 31 NH has one of the lowest teen birth rates in the country. As the 2011 NH State Health Profile reports, teen birth rates have steadily declined since 1990 when the rate was 30 births per 1,000 females age 15-19.32 The most recent statistic for the statewide teen birth rate is 18.4, while the rate
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of births to teenagers in the service area is even lower at 14.7 per 1,000. This rate is approximately one third of the national teen birth rate (42.5 births per 1,000 females age 15-19).33 34 The number of infants born to unmarried mothers (37.1%) is however a statistic that exceeds the national rate of 28.6% for e the non-hispanic white population.. Of birth births from 2006-2008, 39.8% were to Medicaid/CHIP patients.35 Adequacy of prenatal care is an indicator often used to assess the level of access and quality of prenatal services available in a community. At Figure 8. Adequacy of Prenatal Care, 20%, the service area has a slightly higher rate of 2006-2009 late entry into prenatal care compared to the PNC Adequacy Index % Service Area national average of 16% late entry. 36 37 Figure 8 Missing information 3.6% uses the Prenatal Care Adequacy Index to illustrate the level of prenatal care in the service Inadequate 9.6% area. The index considers both the time of initial Intermediate 6.3% entry to prenatal care and the number of prenatal Adequate 42.7% visits compared with standard professional recommendations. Overall, about 83.5% of Adequate Plus 37.8% women in the region received prenatal care NH Department of State, Division of Vital Records documented at the adequate or better level.
Administration, 2006-2008

Child Health
The first years of life are considered the most important for cultivating the foundation for success throughout the life span. For children to have the best health outcomes, they should have regular access to high-quality health care including access to preventive health services such as immunizations and screening tests. Additionally, supporting good personal health behaviors and monitoring behaviors that could indicate the development of problems is important in building a healthy foundation for a child’s development. 38 Lead Testing: Currently, most children in the region are not routinely tested for elevated blood lead levels. Less than half of children in the area (47.8%) are tested by the time they are 3 years old compared to 93% of children 3 years and under tested nationally.39 Lead poisoning can have broad effects on children including intellectual and behavioral deficits.40 In 2009, the service area reported that 3.16% of children tested had elevated blood level counts, which despite being a very small population count is significantly higher than the state percentage of 0.78%. 41 Elevated lead blood levels are typically seen in areas with older housing built before 1950. Older housing stocks are frequently concentrated in urban centers. While Central NH is not devoid of older
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infrastructure, the housing tends towards newer buildings with the average year of construction being 1976. The percentage of housing built before 1950 in the Central NH area is less than 1 in 4 (22%).42 Immunization: Relative to the state and the nation, the Greater Plymouth and Newfound region is effective in ensuring that children are protected from vaccine preventable diseases. In Grafton County only around 17% of children do not receive their recommended immunizations (4:3:1:3:3:1:4 series) versus 26.2% in NH and 34.3% nationally. 43 44 Oral Health: Poor oral health puts children at risk for infection and/or pain and missed school.45 One proven prevention method for Figure 9. Prevalence of Oral Health Indicators decreasing tooth decay is the application of 46 Among Third Graders, 2008-2009 dental sealants. A 2009 NH survey showed that Grafton & Carroll Counties were far Carroll & New Variable behind the statewide percentage of third Grafton County Hampshire graders who had dental sealants (39.8 % Decay experience 46.7 43.9 Grafton/Carroll County; 60.4% NH).47 Lack Untreated decay 17.0 12.0 of preventive dental care and treatment was identified as the top health issue in the Dental sealants 39.8 60.4 community survey (see Section B) and Need treatment recognized by many community leaders as a 16.7 12.0 (early & urgent) pressing health issue (see Section C). The 2009 Need urgent report also shows that statewide dental decay 2.5 1.0 treatment is significantly higher in schools where more than half the children were at or below 185% NH 2008-2009 Third Grade Healthy Smiles-Healthy Growth of poverty. This further supports the local Survey community’s observations that inaccessibility of oral health care disproportionately affects impoverished populations. Healthy Eating & Active Living: Increasing obesity and the associated medical problems is an ongoing trend nationally, and a growing problem among children in the service area. Providing opportunities for children to eat healthy and be physically active are essential to reversing the obesity problem. As detailed in Section B, 11% of community survey respondents described factors associated with healthier eating and active living as the most important area of emphasis for improving health in the community. Nearly 17% percent of third graders in Grafton and Carroll counties are considered overweight and 17.7% are obese. This is comparable to third graders statewide who are either overweight or obese (33.4%).48 A 2003 NH study indicated that higher BMI levels are correlated with lower academic performance and higher rates of absenteeism have been linked with childhood obesity.49 A NH study conducted in 2004 also showed the impact of narrowing opportunities for physical education during the school day. The study showed a decrease from 88% proficiency to 47% in the number of students able to complete a minimum fitness level test from the time of school entry to
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the second year of school. The study showed a steady decrease as the student’s advanced in school years.50 Fortunately, school age children appear to have more opportunities for daily physical activity outside of the classroom. Statewide the percentage of children, age 6-17, who were physically active for a total of at least 20 minutes per day in the past 7 days has increased from 25% in 2003 to 29% in 2007. Similarly, high schools students experienced a 4% increase in weekly level of physical activity.51 Missed School: As previously mentioned, educational achievement is a protective factor for good health. Similarly, a child’s health status can directly affect his/her academic success. Among 6-17 year olds in the service area, 13.4% of them missed between 6 and 10 days of school due to illness or injury in the past year. This is compared to 12.3% nationally among the same age group.52 Also of note, school absenteeism is also associated with involvement in risky behavior, including substance use and risky sexual behavior.53 Substance Use: Assessment of teen health risks and behaviors has been conducted using the Teen Assessment Project (TAP) Survey in the Pemi-Baker Region since 1999 and in the Newfound Region since 2003. Figures 10 & 11 illustrate school trends for use of alcohol, tobacco or marijuana in the 30 days prior to the survey administration. The results reveal some recent improvements on these measures in the Newfound Region and some reversal of significant gains made in the PemiBaker region in previous years. The results demonstrate that a majority of teens are not engaging in behaviors potentially detrimental to their health, but that a significant proportion of teens do report frequent use of alcohol, marijuana and tobacco.

Figure 10.

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Figure 11.

Figure 12 compares the 2009 regional results for 30 day substance use by high school age youth with state and national results for these same measures (identical survey question wording). In general, youth in the region tend to report similar rates of cigarette smoking compared with state and national rates, and lower rates of recent alcohol use. NH and the service area tend to experience higher rates of teen marijuana use when compared with the nation.
Figure 12. Comparison of Regional TAP Results with State & National YRBS Results (2009) For Substance Use in Past 30 Days (Percent of Respondents)

Cigarettes
Pemi: Males Pemi: Females Pemi: Total Newfound: Males Newfound: Females Newfound: Total NH:Males NH: Females NH: Total US: Males US: Females US: Total 22.6 18.0 20.1 20.0 16.2 18.1 21.6 20.0 20.8 19.8 19.1 19.5

Alcohol
35.4 39.4 37.4 33.0 32.0 32.9 39.2 39.4 39.3 40.8 42.9 41.8

Marijuana
28.8 23.3 25.8 33.7 18.6 26.4 28.1 22.9 25.6 23.4 17.9 20.8

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Despite the fact that a large majority of youth are not engaging in frequent high risk health behaviors, including substance use, there remains a subgroup of youth who are. One of the most compelling findings from the TAP survey studies is the association between one risky health behavior and other risky behaviors. Figures 13 and 14 display the association between binge drinking (5 or more drinks over a few hours; ‘drinking to get drunk’) and other high risk behaviors. As the charts display, youth who report binge drinking in the past 30 days are significantly more likely to also report other high risk health behaviors.
Figure 13.

Figure 14.

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There is significant published evidence that substance use and other health risk behaviors put youth at risk for delayed emotional and intellectual growth; developing problems with schools, friends and families; incurring ill health and reduced longevity; accidents; suicide; and unwanted pregnancies. Given the risks accompanying these behaviors, it is incumbent upon the community to attempt an understanding of what can be done to minimize the likelihood of these youth choices. One possible action is to increase the protective factors for youth. Protective factors “protect” or lessen the likelihood that youth will participate in behaviors that have negative health and social outcomes. These protective factors exist at each level of an ecological model of health promotion including individual and peers, family, school, and community.

ADULT HEALTH
Diabetes: Diabetes is a disorder causing high blood glucose levels that impair the circulatory system putting a person at risk for many serious health conditions including: heart disease, blindness, nerve, and kidney damage. Changing lifestyles including eating habits and levels of physical activity have contributed to an epidemic of diabetes across the United States. The percent of adults in the Greater Plymouth public health network service area who have ever been told they have diabetes (9.4%) is slightly higher, but statistically similar to the state (7.2%) and national percentages (8.4%).54 When looking at diabetes rates across different socioeconomic groups, rates are twice as high statewide for residents with less than a high school education that those with a college degree. Even more dramatic variation is present between income levels; those earning less than $15,000 a year have diabetes rates three times higher than those earning $75,000 a year or more.55 The burden of morbidity and mortality from diabetes is also high in the service area. Compared with a national rate of 25.1 deaths per 100,000 people with diabetes as an underlying cause, over 58 per 100,000 service area residents die with diabetes listed as an underlying cause.56 Additionally, the service area has a relatively high rate of diabetes related amputations (34.6 per 100,000) compared with the state rate (19.9), although it is similar to the national rate (37.5 per 100,000). 57
Figure 15. Diabetes
Indicator Diabetes prevalence, Percent of all adults Diabetes related lower extremity amputation inpatient discharges, Rate per 100,000 Diabetes as underlying cause of death, Rate per 100,000
NH DHHS Hospital Discharge Data Collection System, 03-07 CDC National Diabetes Surveillance System, retrieved 2010 NH Division of Vital Records Administration Death Certificate Data, 05-07 * NH Data missing towns: Lincoln, Waterville Valley, Wentworth, Orange, Woodstock

Service Area 9.4% 34.6 58.1

NH State 7.2% 19.9 73.1

US 8.4% 37.5 25.1

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Healthy Eating & Active Living: Similar to diabetes, changing lifestyles have spurred a nationwide increase in the number of overweight and obese adults. In the Greater Plymouth Public Health Region, 33.6% of adults are overweight and 24.1% are obese, which is comparable to the statewide rates of 37.2% overweight adults and 25.8% obese adults, and similar to national rates.58 Daily fruit and vegetable consumption in the area matches the statewide rate, with around 26% of adults reporting that they consume fruits and vegetables five or more times per day. 59 Despite the perceived lack of indoor exercise facilities in the area (see infrastructure needs addressed in Section B & C), residents exceed the percentage of adults statewide (53.5% NH) who engage in moderate or vigorous physical activity (65% region).60

Figure 16. Healthy Eating & Active Living
Health Behaviors (Percent of Adults) Obese Overweight Fruits and vegetables five or more times per day Moderate or vigorous physical activity
Data Source: 2011 NH Regional Health Profiles

Greater Plymouth PHN 24.1 33.6 26.3 65.2

New Hampshire 25.8 37.2 28.0 53.5

Cardiovascular Health: As detailed under leading causes of death, death from diseases of the heart is the second killer in the service area. The service area faces a mortality rate of 183.6 from diseases of the heart, though nationally the rate is 240.8.61 62 When considering both principal and secondary diagnoses the rate of congestive heart failure in the area is 787.8 cases per 100,000 population. Still higher, hypertension affects 2,475.5 persons per 100,000 service area residents when including secondary diagnoses. Unfortunately comparable state and national benchmarks are not available. When considering the confidence intervals, rates have remained mostly constant in the region from 1998-2007..63 Nearly 21% of adults in the public health region reported being diagnosed with high blood pressure, compared to 27.6 % statewide.64 Also comparable between the region and the state are rates of being tested
for high cholesterol in the past 5 years (78.2% in Greater Plymouth PHN and 81.9% statewide).65

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Figure 17. Service Area Change in Cardiovascular Health 1998-2007
3,000 Standardized rate per 100,000 population 2,500 2,000 1,500 1,000 500 0 1998 to 2002 2003 to 2007

2011

Between the 5-year spans of 1998 to 2002 and 2003 to 2007, the admission rate of angina pectoris was significantly lower during the latter 5-year period. Hypertension shows no statistically significant differences in the inpatient admission rates between the 2 periods. Congestive heart failure admission rates were significantly lower between 1998 and 2002. NH DHHS, 2010

Angina pectoris

Congestive heart failure

Hypertension

Figure 18. Cardiovascular Rates in Service Area Hospital Admissions by Diagnosis Congestive Heart Failure Hypertension 1998-2002 Service Area Rate Per 100,000 By Primary Diagnosis i 222.6 25.8 2003-2007 Service Area Rate Per 100,000 by Primary Diagnosis i 212.9 35.1 2010 US Rate per 100,000 i i 502.8 50.2

i. 2003-2007 NH Health Statistics & Data Management ii. HRSA, Bureau of Primary Health Care, 2010

Adult Asthma: The 2011 NH State Health Profile reports that NH has among the highest rates of asthma in the nation with 10.2% of adults who currently have asthma. Rates of adult asthma are slightly higher, although not statistically different, in the Greater Plymouth public health region compared to the state with nearly 12% of adults reporting a current asthma diagnosis.66 As the state report notes, “Among the possible reasons for poor asthma control are inadequate insurance coverage, including coverage for drugs, limited access to primary care providers…” Considering the high rate of uninsured residents in the service area, lack of access to services may be one driver of the higher than average rates of asthma. Further evidencing resident’s lack of access to asthma care is the high rate of asthma related emergency department visits. Compared to the state rate of 491.1 asthma emergency department visits per 100,000 people, Grafton County’s rate is higher at 587.3.67
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Figure 19. Adult Asthma
Indicator Current Asthma, Percent Adults Asthma Emergency Department Visits Per 100,000 (all ages) Greater Plymouth Public Health Region 11.8% 587.3

2011

New Hampshire 10.2% 491.1

NH Hospital Discharge Data Collection, 2006 & 2011 Regional Health Profiles

Mental Health: Poor mental health can affect various aspects of an individual’s life including ability to access care, be productive and engage in fulfilling relationships.68 In Grafton County, 36.3% of adults reported that there were days in the past month when their mental health was not good.69 Additionally, the prevalence of adults in Grafton, Coos and Carroll Counties reporting having at least one major depressive episode in the past year (8.43) exceeded the national average of 7.55.70 Suicide rates for the service area (11.5 per 100,000) mirror the state (11.2) and US rates (11.0). 71 Substance Use: Long term heavy alcohol consumption increases an individual’s risk for many health problems including heart disease and stroke, as well as mental health problems It may also increase instances of homicides, suicides, domestic violence, and child abuse.72 The percentage of adults who engage in heavy drinking and binge drinking in the public health region is near equal to that of that state with regional percentages of 4.6% and 14.9%, respectively.73 Reported illicit drug use in the past month is higher for Grafton, Carroll and Coos counties (11.5%) than the state (10.3%) and US rates (8.2%).74 Regionally and statewide, inpatient discharges with a principal diagnosis of a substance abuse related mental health disorder are 427.7 and 438.2 per 100,000 population, respectively. Contrary to public perception noted in Section B & C, young adults in the area (15-24 year olds) have lower rates of substance abuse related mental health condition inpatient discharges (268.2) compared to the state overall (390.6).75 Community perceptions and identified issues related to emergency services for those with mental health and substance use problems are further described in Sections B & C. Among adults in the region, 18.2% are smokers while only 16.5% of adults throughout the state are currently smoking.76 As noted earlier in the report, cigarette smoking is a major cause of chronic lower respiratory disease, a leading cause of mortality in the service area.

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Personal Safety: “Every 14 seconds, an adult in the United States is treated in an emergency department for crash-related injuries.”77 Ensuring that drivers and passengers are buckled up every time they are in a car can reduce one of the leading causes of death by 45-60%.78 Seatbelt use among adults is dramatically lower in New Hampshire and the service area than nationwide. While nationally 85% of passengers and drivers always wear seatbelts, only 65.6% of adults in the state and 60.9% of adults in the region report always wearing seatbelts.79 New Hampshire is currently the only state in the nation that does not have a mandatory safety belt law. Mandatory laws, as well as primary seatbelt enforcement laws, which permit an officer to pull cars over and issue tickets solely because drivers and passengers are unbelted, are strongly correlated with increased seatbelt use.80

Figure 20. Health Behaviors
Health Behaviors (Percent of Adults) Substance Use Heavy drinking Binge drinking Any Illicit drug use in past month i Greater Plymouth Public Health Region 4.6 14.9 11.48 New Hampshire 6.0 16.1 10.3

Current smoking 18.2 16.5 Personal Safety Always use seatbelt 60.9 65.6 All sourced from following unless otherwise cited: NH Bureau of Public Health Statistics and Informatics, 20062009
i. National

Survey on Drug Use & Health, 06-08 statistic for Grafton, Carroll, & Coos

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Environment
Transportation: A 2010 transit feasibility study of 19 towns in the 21 town service area highlighted the necessity of access to transportation for the relatively small Figure 21. Reported Difficulty Traveling in Service Area population dispersed over more than 81 Always 750 square miles. Among transit 11% survey respondents, 20% reported Often 9% frequently or always having difficulty Never traveling in and around the service 49% area. Additionally, medical services Sometimes 31% were the second most frequently cited reason for travel in and around the area. The study also noted a need for transportation to social service North Country Council-Transport Central, 2010 providers, such as Head Start, particularly in the Plymouth area. In the CNHHP community health needs survey, about 51% of respondents identified “public transportation” as a service or resource that should be focused on for improvement to support a healthy community; second only to improved job opportunities (56% of respondents). Similarly, when asked in an open-ended question to identify the most difficult aspect of living in their community, the top difficulty mentioned (18% of all respondents) was the lack of transportation including lack of public transportation Housing: Where public housing is available in the area, residents are waiting a minimum of 8 months.82 Those stuck in this waiting period may become homeless. A January 2011 point in time count of the homeless population in Grafton County found 68 individuals currently in shelter care and 19 homeless individuals who were unsheltered. Among those unsheltered, 11 of the individuals were part of a homeless family (total of 3 families). An additional 8 individuals were temporarily residing with family or friends.83

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Section B Community Survey Summary & Analysis

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Methodology: A 14 question community needs survey was distributed throughout the CNHHP service area from March through June 2011. The survey was distributed using online links, email blasts, display stands, asking front desk staff to prompt visitors to complete the survey, and asking people to complete the survey outside of the Bristol Shop & Save. A total of 600 completed surveys were returned; representing about 2.2% of the entire adult population in the service area (427 hardcopy surveys and 173 using the online survey collector.) Survey respondents were asked to consider a number of health-related issues and were provided an opportunity to comment on what they would do to make their community a healthier place. With regard to the concept of community, respondents were instructed as follows: “Your community” can mean different things to different people. For the purpose of the survey, your community can be as big as the Greater Plymouth & Newfound area or as small as your town. Answer the survey questions by thinking about the area you see as “your community”. As an incentive to complete the survey, respondents were informed that $2 would be donated to a local charity by the Central NH Health Partnership for each local resident that completed the survey. Respondent Demographics: Of the 600 community health needs surveys completed, at least one survey was received from every town in the Central NH Health Partnership service area. As displayed in figure 22 and 23, the survey corresponds geographically with the proportion of the service area population represented by each town.
Figure 22. Comparison of Survey Sample With Regional Population By Town % of Total Service Area Population 4.6 5.9 3.1 8.7 9.5 3.3 1.0 0.2 3.8 1.7 1.7 6.0 4.7 6.2 0.9 19.9 4.2 7.1 0.7 2.6 3.9 100 % of Survey Respondents 5.1 7.1 3.6 12.9 10.4 1.3 0.4 0.2 0.5 2.2 2.2 5.8 1.5 2.7 0.2 23.1 5.6 6.2 0.5 2.6 1.1 3.8 100 Difference 0.5 1.2 0.5 4.2 0.9 -2.0 -0.6 0.0 -3.3 0.5 0.5 -0.2 -3.2 -3.5 -0.7 3.2 1.4 -0.9 -0.2 0.0 -2.8 3.8

Alexandria Ashland Bridgewater Bristol Campton Danbury Dorchester Ellsworth Grafton Groton Hebron Holderness Lincoln New Hampton Orange Plymouth Rumney Thornton Waterville Valley Wentworth Woodstock Other TOTAL

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Figure 23.

As displayed in figure 34, there is also good overall correspondence between the age breakdown of survey respondents and the survey sample. The population age 24 and under is slightly underrepresented proportionally, however the next youngest age bracket (25-34) is where the most of the proportional difference is accounted for.
35 30 25 20 15 10 5 0 18-19 20 to 24 25 to 34 35 to 49 50 to 64 65 to 74 Age in years 75+

Figure 24. Age distribution of the Service Area and the Survey Sample

% of Service Area Population % of Survey Sample

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Survey respondents were also asked to indicate their household income bracket and about 86% of survey respondents did provide that information. Figure 25 displays the breakdown of household income by income bracket for the survey sample. The median value for this categorical question can be used to roughly approximate the median income for households represented in the survey. Using this technique, the median household income is estimated to be $42,180 which is similar to the median household income for the region of $46,218 as estimated by the US Census Bureau. Figure 25. Household Income CNHHP Community Needs Survey Sample
8.0% 11.9% Less than $10,000 $10,000- $25,000 $25,000- $49,000 19.6% 18.1% $50,000- $74,000 $75,000- $100,000 More than $100,000 26.3%

16.1%

Figure 26 shows additional information describing the demographics of survey respondents. A significant majority of respondents are female (about 76%), have lived in the Greater Plymouth/Newfound region for about 21 years on average, and have a median household size of 3 people.
Figure 26. Additional Respondent Demographics Gender Male 24.3% Female 75.7% Mean Median Number of Years in the 20.9 years 18.0 years Region Number of People in the 2.9 3 Household

Minimum 1 month 1

Maximum 86 years 13

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Most Pressing Health Issues: The survey asked respondents to indicate what they thought are the most pressing health issues in their community today. Respondents were instructed that they could select up to 5 different items and/or fill in an open-ended “other” category. The top 10 most pressing health issues reported by area residents are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Access to dental health care Access to enough health insurance Alcohol & drug use Not enough exercise Poor nutrition/unhealthy food Access to mental health care Youth alcohol & drug use Mental illness Access to primary health care Smoking/tobacco use 50.2% of respondents 39.2% 37.5% 35.9% 34.7% 34.4% 34.1% 33.7% 32.4% 25.3%

Access to specialty services was noted as a pressing health issue by 8.5% of respondents. Given the opportunity to specify which specialty services, the most common responses were: more local service options in general (not specific) (1.5%), mental health services (1.0%), and transportation (0.7%). The complete ranking of “pressing health issues” is displayed by figure 27 and the complete set of tabulated and open-ended results are included in Appendix I.
Figure 27.

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Most Pressing Community Safety Issues: The survey next asked respondents to indicate what they thought are the most pressing safety issues in their community today. Again respondents could select up to 5 items and also write in an issue not listed. The top 7 most pressing safety issues reported by area residents are: 1. 2. 3. 4. 5. 6. 7. People under the influence of alcohol or drugs Domestic violence or partner abuse Bullying/cyber-bullying Child abuse or neglect Being prepared for an emergency Youth crime Crime 64.1% of respondents 50.3% 49.8% 49.0% 25.4% 21.8% 21.3%

The most common “Other” responses for most pressing safety issues are Driving/Traffic safety (1.5%) and ‘not enough activities for youth (0.5%). The complete ranking of “pressing safety issues” is displayed by the chart below and the complete set of tabulated and open-ended responses are included in Appendix I.
Figure 28.

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Services or Resources to Support a Healthy Community : The survey asked respondents to indicate what services or resources should be focused on for improvement to support a healthy community. Again respondents could select up to 5 items and also write in an issue not listed. The top 9 areas of focus to support a healthy community as reported by area residents are: 1. 2. 3. 4. 5. 6. 7. 8. 9. Job opportunities Public transportation Access to affordable housing Youth programs and support Access to affordable food Parenting support Support for older adults Job training Quality child care 55.8% of respondents 50.7% 49.8% 36.1% 31.3% 28.9% 26.7% 26.5% 25.2%

The most common “Other” responses for services or resources to support a healthy community are: Access to affordable health care (1.3%), domestic violence education/support (1.2%), mental health support/resources (0.5%), and poverty reduction (0.5%). The complete ranking of “services or resources for improvement to support a healthy community” is displayed in figure 29. The complete set of tabulated and open-ended responses is included in Appendix I.
Figure 29.

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Access to Services: Survey respondents were asked whether, in the past year, they or someone in their family had difficulty getting the services they needed. About 44% of respondents selected “yes”, they had experienced difficulty accessing services. Respondents who selected “yes” were asked two follow-up questions. The first question asked which services they or their family have difficulty accessing. The top 5 services with access difficulties reported by survey respondents were as follows: 1. 2. 3. 4. 5. Dental care for adults Primary health care Mental health Social/human service agencies Specialty Health Care
Fig 30.

2011

23.5% of all respondents 18.0% 10.5% 9.3% 7.2%

Please note that the percentages reported above and on the chart below are the proportion of all survey respondents (n=600); not just of the subset of respondents indicating access difficulties. It is reported in this manner to provide perspective on the proportion of the whole population reporting this experience. With respect to “specialty health care”, respondents were provided the opportunity to specify a particular specialty or specialties. The most common responses with respect to difficulty accessing specialty health care are Orthopedics (0.5%), Diabetes (0.3%) and Dental (0.3%). “Other” services commonly mentioned with respect to access difficulty not included on the list are transportation (0.8%) and financial/eligibility assistance (0.7%).

Figure 31.

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Respondents reporting difficulty accessing services were also asked why it was difficult to access the services they needed. The top reasons cited were as follows: 1. 2. 3. 4. 5. 6. 7. 8. Could not afford to pay Had no health insurance Service I needed was not available I was not eligible for services Did not know where to get services Had no way to get there Waiting time to receive the services was too long Service was not accepting new clients/patients 24.7% 21.8% 13.0% 12.8% 10.5% 9.7% 8.0% 7.0%

“Other” reasons mentioned for access difficulty included coverage/eligibility limitations (0.8%), no dental insurance (0.7%) and travel/distance (0.5%). Again, it is important to note that the percentages reported above and on the chart below are the proportion of all survey respondents to provide perspective on the proportion of the whole population reporting this experience.

Figure 32.

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Programs and Services People Would Use: The survey included a list of existing or potential services and asked respondents to indicate which of the programs or services they or their family would use if it was more available in their community. The top programs or services respondents would use if more available were: 1. 2. 3. 4. 5. 6. 7. Fitness/exercise program Stress reduction and relaxation classes Public transportation Weight loss program Nutrition/cooking program After-school activities for youth Job training 49.2% percent of respondents 41.2% 35.9% 34.2% 30.9% 28.5% 27.2%

People who selected “medical services” were provided the opportunity to specify a medical service. The most common responses were dental care (0.7%), affordable health care (0.5%), primary care (0.5%) and ‘specialists’ ( in general) (0.5%). Figure 33 displays the proportion of all respondents selecting each option on this question.
Figure 33.

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Community Perceptions & Ideas for Building a Healthier Community : Near the end of the CNHHP community health assessment survey, area residents were asked three open-ended questions about what they liked best about living in their community; what was most difficult about living in their community; and, if they could change one thing that would contribute to better health in their community, what would it be? In total, nearly 1,400 comments on these questions were submitted addressing a range of topics and issues. These comments were each reviewed and categorized to identify themes for each question. In some cases, comments addressed multiple issues and were parsed for assignment to different categories. The table below shows the major categories arising from the question, “What do you think is the best thing about living in your community?”. The top theme in response to this question was ‘the people’, including families, friends and neighbors and, more specifically, a sense of community connection and community caring. The second, and undoubtedly related, theme was appreciation for living in a rural community. This theme included concepts of peace and quiet, small town living, and the pace of life.
Figure 34. What do you think is the best thing about living in your community? family, friends & neighbors; helpful people, sense of community support small community, rural; quiet natural environment, outdoor activities access/proximity to services, programs; cultural activities safety, low crime good schools; educational opportunities Percent of all respondents 25% 17% 16% 9% 7% 2%

“I think the people are the best thing in the area. The area is filled with truly wonderful people. -Pemi River area survey respondent

“I like living in a small quiet town.” -Baker River area survey respondent

“I love living in a rural community because we know our neighbors and provide assistance to each other in times of need.” -Newfound area survey respondent

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The second question, which asked what was most difficult about living in their community, prompted some greater variation in responses, but also a number of responses that are the ‘flip-side’ of living in a relatively small rural community. The top difficulty mentioned by survey respondents (18% of all respondents) is the lack of transportation including lack of public transportation. The second most common theme – the long distances required for travel to work, services and activities - is related to the transportation issue.
Figure 35. What do you think is the most difficult thing about living in your community? lack of transportation/public transportation travel distances to services/cost of travel lack of jobs/employment opportunities access/availability of local services (mental health and dental broken out separately) lack of physical, cultural, social activities; and related environmental supports financial burdens; taxes isolation of rural setting; lack of community connections, diversity winter lack of affordable housing alcohol, tobacco & drug use proximity to the college/college students access to mental health services access to dental care Percent of all respondents 18% 13% 8% 7% 7% 6% 5% 3% 3% 2% 2% 1% 1%

“Nothing is close - have to drive to everything. If you don’t have a carit is difficult to get anywhere.” -Survey respondent from Campton

“Lack of public transportation is a huge challenge, especially for those who cannot afford an automobile. This area really needs more public transportation than just the seniors’ bus and the college shuttle.” -Survey respondent from Plymouth

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The final open-ended question asked, “If you could change any one thing that you believe would contribute to better health in your community, what would you change?” This question also prompted a range of opinions and thoughtful suggestions. Interestingly, the most common theme (11% of respondents) can be categorized as “Healthier Eating, Active Living”. This category included a variety of suggestions for community health improvement through a focus on improving food choices, including food served in schools, and increasing community resources to promote indoor and outdoor exercise. The next most common theme was more accessible and affordable health care and health care insurance. This theme is distinguished from the third most common category which addresses a perceived need for more health care delivery capacity (e.g. “more clinics”, “more specialists”). Other commonly mentioned areas for improving community health included increasing transportation options and more resources for family and community activities including a multiple comments suggesting the need for a community center.
Figure 36. If you could change any one thing that you believe would contribute to better health in your community, what would you change? healthier eating/active living access to health care/affordable care/affordable health insurance; lower the cost of care; free care expanded capacity, quality of health services transportation resources for youth, family, community social & recreational activities alcohol, tobacco and other drug prevention & treatment expanded access to mental health services expanded health education, outreach and wellness program jobs/job training collaboration, communication, community involvement access to dental care senior services economic issues/poverty Percent of all respondents 11% 9% 8% 6% 6% 4% 4% 4% 3% 2% 2% 2% 2%

“Opportunity for adults to participate in local activities like softball or other sports.” -Survey respondent from Alexandria

“Community focus on healthy eating, exercise, and weight loss.” -Survey respondent from Holderness

“A change I would really like to see would be for everyone to receive excellent dental and medical care, with little to no out-ofpocket expense because of insurance coverage.” -Survey respondent from Plymouth

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Section C Conversations with the Community
(Community Leader Interviews & Focus Groups)

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Conversations with the Community
Methodology: As part of the community needs assessment, the Community Health Institute conducted a series of 22 community leader interviews and 3 focus groups to provide richness and nuance and to validate the quantitative data collected by CHI through secondary sources and the community survey. Community leaders were defined as residents of the service area that also play key roles in health care or social service delivery, or work in public services that impact the community’s risk and resiliency factors. All 10 CNHHP board members of the partnership were interviewed and the additional 12 interviews were identified by the suggestions of the board. Around 15 of the community leaders were identified as representing the voices of the Greater Plymouth area, and 7 of the respondents represented the Newfound area. As detailed in the table below, additional considerations were made to ensure as many sectors were represented as possible. Three focus groups were also conducted as part of the assessment. The first focus group included 10 social service providers for the service area; the second focus group included 18 parents in the service area who were part of the Whole Village Family Resource Center parent education group; and the third focus group included 5 faith leaders in the community. Figure 37.
Sector Education Law Enforcement & Emergency Management Community and social services Community Leader Interviewed Superintendent Extended Learning Coordinator University Dean Chief of Police Homeless Shelter Management Community Center Management Nutrition Service Management Family Resource Center Management Welfare Officer Health Center CEO Health Center Medical Director Regional Clinic Director Dental Practice Co-Owner Pediatrician Hospital Management Rehabilitation Centers Management Behavioral Health Center Management Drug Prevention Program Management Commercial Sector Chief Financial Officer Economic Development Committee Board Member Senior Center Management Home Health & Hospice Management Community Center Activities Director

Adult Health Care

Pediatric Health Care Emergency services Rehabilitation Care Mental & Behavioral Health Care Business & Economic Development Older Adults Healthy Eating, Active Living

Feedback from the interviews and focus groups are compiled here and organized by key themes. For each pressing health issue identified, respondents were asked to note any existing resources working to address the issue, and share any strategies or recommendation they had for alleviating the issue.
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Respondents were also asked general questions about access to care, quality of care and overall quality of life. Focus group notes and interview scripts are included in the appendix.

The Service Area Landscape
Overall Health: When asked about the overall “I would say fair to poor health because it health of the service area, the general consensus of the is so hard to get health insurance that I community is that the service area is in fair to good health overall, but with the poor population think a lot of people just skip it because disproportionately afflicted with poor health. All they figure I’m not going to the doctor, interviewed told the story of the “haves” and the because I can’t afford it.” –Ashland female “have-nots”-what they described as a deep divide between those with access to health and social services and those without the needed access. The divide is driven by factors including access to health, educational attainment, poverty status, distance to services, and overall health/mental/behavioral status. One social service provider noted, “I would say it’s not a dichotomy, but a disparity in the health of the community.” In response to most questions about health indicators, community leaders expressed the great differences in these two population groups. “There is potential for everyone in the community to have a high quality of life, but not all have the opportunity to enjoy it.” Quality of Life: Similar to health status, a resident’s quality of life is strongly driven by their socioeconomic status. For those with health insurance and employment there are many resources in the community that contribute to a high quality of life, but for those who struggle on a daily basis quality of life looks more grim.

One example given was the great economic diversity among the towns in the SAU 4 school district, and similarly between Plymouth and nearby Rumney. Despite the disparities, the Greater Plymouth and Newfound area are seen by the community as a “great place to live”. Plymouth is considered a hub for arts, sports, and intellectual activities. Many of these activities are available due to the local university, Plymouth State University. The university has maintained around 4,000 undergraduate and 2,500 graduate students (not all based in Plymouth) over the past five years. During that time leaders have noticed an increase in arts and recreational opportunities mostly in Plymouth, but also in other areas. Services, activities and amenities that were noted as important to the quality of life in the community are:   Good regional access to high speed internet Arts & Entertainment  Flying Monkey in Plymouth  Plymouth Friends of the Arts
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Summer concert series in Plymouth and Bristol Winterfest in Bristol Halloween parades in Plymouth and Bristol Various programming at the Minot Sleeper Library in Bristol & Peace Public Library in Plymouth  Various performances and gathering at the Plymouth amphitheater Sports entertainment such as:  Teen nights at Ice Arena in Plymouth Added recreational areas for seniors at the Plymouth Senior Center Annual Gordon Research Conference in Plymouth

A community leader used a single night to describe the downtown vitality in Plymouth saying that in one night the Flying Monkey had a sellout performance of 500 people; the Ice Arena sold out 800 seats for a hockey tournament; Voices against Violence sold out 200 seats at local fundraisers; and a concert at Silver Hall had a sellout crowd of 700 people. Lines for restaurants were out the door, and “Main Street was very alive.” On the quality of life, many community members expressed the sentiment that ‘your life is what you make of it’, noting that despite a resident’s employment or health status, there are free opportunities to enjoy the local environment. A Lincoln resident expressed this sentiment saying, “Up where I live, it is what you make it. A lot of people don’t have a lot of money, but we are up in the White Mountains and there is a lot of stuff you can do that doesn’t cost money. Or you can sit inside all day and not do anything, so it is what you make it.” Faith leaders added that often residents need to be taught how to access free or low-cost activities, and that it is often a skill impoverished individuals in the community lack. Other community members noted that they feel very safe in their communities. While some felt the area had a relatively slow pace of life, others noted that busy working families have led to childhood health and behavior issues that could affect the quality of life overall. Several noted that unsupervised children lead to increased petty crime, youth substance use, inactivity, and unhealthy eating habits. Some community suggestions for improving the quality of life in the area include the following:  Affordable housing in downtown Plymouth is needed for the community. A recent proposal to build “Plymouth Woods” included six reserved apartments for low income and minimal needs residents; however, the community leader reports that the project was canceled due to public disapproval. Currently, homeless community members, who may not have vehicles to commute downtown are on two year waiting lists for subsidized housing. It is particularly difficult for single people to get housing.

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 

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Upscale condos and townhouses should be developed in downtown Plymouth for new retirees looking to move back to Plymouth. They are an audience who might be interested in contributing financially to community initiatives. There are some plans to build a skate park downtown, and community members hope this plan is implemented. They feel it will be a great outlet for local youth. A local senior center director would like to see an expanded senior center with a pool, washers and dryers, an activity room and a daycare. He believes the addition of a daycare would be a valuable way for the youth of tomorrow connect with the elder population. Several focus group participants expressed a desire for affordable after-school and recreational activities for children, such as a local youth center, and more flexible day-care options. There should be more activities available for high school students. A faith leader emphasized the need for outdoor activities for youth that don’t require a car, such as more playgrounds accessible by foot or bike. Low cost or free skiing for youth, and additional community gardens were also recommended.

Economy: The economy is seen by many as an ongoing risk to the health of the community. Much of the area's seasonal employment has seen a decline as a result of the recession, including the closing of Tenney Mountain Ski Area. Those who still have seasonal employment face high job insecurity and no insurance coverage. Additionally, the rural area makes it more challenging for residents to travel for employment opportunities. Unemployment and lack of insurance coverage have launched many residents into what they call “survival mode”, focusing on day to day necessities often leaving preventative care to the wayside. A social service provider commented, “Basic survival is more of a day to day struggle [for the poor] so they can’t even conceive of going to a doctor regularly, or do wellness visits, because they are in a survival mentality.” A Plymouth area resident reported the following:

“I was the owner of a company for about 16 years, but because of the economy it went belly up about 2 years ago; since then I have been unemployed. I think the economy has a lot to do with what’s going on…especially around here. I think that is the prime factor – people have to survive. That is what I have been doing the last 2 years. I will do whatever I can do, because that is the only way to make money. That is my prime thing – trying to figure out how to make money. All the other considerations, health insurance, everything, it just doesn’t even matter. - Plymouth area male

Additional consequences of the economic recession that were identified include the following:  A local police department reported higher rates of depression and suicidal thoughts as a result of joblessness.
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Homelessness continues to be an issue in the service area. The Bridge House, a co-ed homeless shelter in Plymouth, is currently over capacity for its male clients. In describing those that seek shelter services, a community leader said, “Participants in need of a homeless shelter in Grafton County have exhausted all financial and social resources. They are not people that have just recently been laid off, but people that have tapped every friend and family member for a couch to sleep on.” Patients are ending up with piles of back bills that they don’t know how to deal with.

New initiatives in the service area that are addressing the economic downslide include the following:  The Plymouth Regional Chambers of Commerce recently started a Central New Hampshire Young Professionals Group that tries to support and encourage young professionals in the area to be involved in business opportunities and keep talented youth in the area. PSU is seeking funding to start a business incubator that encourages college students to stay in Plymouth and foster their business ideas. The Bridge House started a gift shop to teach homeless clients retail skills. Waterville Valley Ski Resort was recently brought back into private hands, and the owners are making a big commitment to return it to a more rural family based NH setting. Ashland Lumber is building a new expansion in the area. “NH is a tourist economy and Plymouth is on the fringe.”

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Community leaders and members also provided suggestions for ways to stimulate the economy: 

Stimulating tourism in the area would increase revenue for local businesses and seasonal housing without putting a burden on public resources like schools, and health services. Plymouth should promote itself as a place to stop for amenities along highway 93. A community leader noted, “Plymouth is the first real hamlet you see on your way up 93. There is no prettier setting than that little town of Plymouth.” Someone like Alex Ray or other culinary leaders in the community could start a culinary job training program that that teaches cooking skills and general food service skills for residents that are unemployed or homeless. There should be a greater focus on alternative education, including vocational training programs and apprenticeship programs. Trades are a valuable option for kids that don’t want to go to college.

Transportation: Transportation continues to be a challenge in the service area’s rural environment. With virtually no public transportation, residents are dependent on their automobiles and are often prisoner to severe weather conditions. Transportation limitations seem to be felt

“Access to transportation affects everything from getting to a doctor or dentist appointment to holding a job.” –welfare officer
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particularly strongly by Newfound community members who feel that people and services are often great distances from each other. Community members and leaders specifically mentioned the following transportation considerations:  Students from all over the Newfound area come to Bristol for school, which makes busing and transportation for after school programs a logistical and financial challenge. When not in after school programs, most Newfound area students are limited to their houses and are limited to social life on their computers due to an inability to get to each other without a car. Service providers added that transportation to get to employment trumps any kind of transportation to health care or mental health. Using the car to get to work and put food on the table is more of a priority than using the car for health care. Community members agreed noting that despite some existing resource for medical transportation, more convenient and accessible options are desirable. A local law enforcement official noted that criminals in the area consider revocation of their license for two years to be far worse punishment than spending 30 days in jail.

The only public transportation services identified by respondents were the Plymouth Senior Center bus and the Plymouth State University shuttle which takes passengers to the Wal-Mart in Plymouth and to Mid-State Health Center. Individual organizations have taken measures to help alleviate some of the transportation problems among their constituents. One dental practice co-owner offers support to longtime patients by having a driver pick them up for appointments when located nearby. A local faith fellowship has implemented an “extended family committee” which helps fellow parishioners get to medical appointments. One recommendation for a way to improve the system is implementation of a RideShare program, where people could rent cars for specific periods of time. Collaboration: Leaders in the community feel there is a strong spirit of collaboration among organizations in the service area and a similar enthusiasm for community support among the residents. A Bristol service worker commented, “There is great collaboration out there. If you just call them, you will get some help in some way.” Of the community, leaders said:    “There is a real spirit in this town. At Christmas time, the local residents roll up their sleeves and decorate the main street and the rest of the town.”

“You’d be pressed to find a community more dedicated and spirited about volunteerism.” “The partnerships and organizations in the Newfound area work together, play together and pray together.” Initiatives and events like the local old home days, community fundraisers, and sports leagues do a lot to bring the community together.

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 A community leader involved in economic growth for the area noted, “We are getting better at working together as a medical community…we are not competing for patients anymore.” Parishes and fellowships in the area organize “extended family committees” and other support groups for their community.

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Role of CNHHP: Leaders are continually impressed with the talent in the Central NH Health Partnership and recognize its significant growth in the past five years. The partnership is seen by some leaders as an open and fully collaborative partnership. Leaders note that collaboration through groups like CNHHP is essential with the explosion of non-profits in the area. Where there used to be only a few local non-profits, now there are about 15 non-profits all vying for the same funding. Among those leaders who worked closely with the Newfound area, several noted the challenges of overlapping health partnerships. CCNTR (Caring Community Network of the Twin Rivers) and CNHHP (Central NH Health Partnership) both serve Alexandria, Bridgewater, Groton, Bristol, Danbury, Hebron, and New Hampton. While some note that this overlap affords these communities additional programming and funding opportunities, others feel that the overlap feeds confusion and competition. One Bristol area leader described feeling as though the two partnerships want to be associated with the Bristol area when it makes for a better application, but don’t when it isn’t to the partnership’s benefit. Some comments from the community on the benefit of the partnership include the following:   “The Central NH Health Partnership is the top of my list [for promising new efforts being done in our community].” Community members specifically noted the high level of communication and coordination between health care organizations. As a focus group participant noted, “The network that Plymouth has for social services is a lot tighter and a lot more in-depth than what the “We [CNHHP members] are partnering for the health of the community.” –board member Laconia-Meredith area has . . . . So I definitely got to give this community ‘props’ for that.” A local leader in health services noted that she has seen an increase in health education and physician education through the partnership.

“There is a push and pull between the regions over who gets us- sometimes [they] want our region and sometimes they don’t. They only want you when it will help their numbers.” -Newfound area resident

Some strategies and recommendations for sustaining and enhancing the partnership include the following:
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The partnership should consider conducting needs assessments, engaging in collaborative planning, and establishing quality measures for the partnership. The partnership should span both worlds of clinical services and public health. The partnership should consider its own sustainability, since it takes so long to get new players and leaders to the table.

Pressing Health or Health Care Issues
Active Living: Community leaders from across the sectors continually identified an overweight population and high rates of obesity as one of the most pressing health issues facing the service area community. Service providers see both adult and childhood obesity as serious risk factors for future health issues. One interviewee shared results from a recent measure of BMI counts at New Hampton Community School, which found that 50% of 3rd and 5th graders, and 21% of Newfound area kindergarteners are overweight or obese, and 21% of Newfound area kindergarteners are overweight or obese. A shortage of fitness facilities and a resulting lack of enough exercise by residents are among the primary reasons for obesity identified by local leaders. This perspective is supported by responses from the community survey, which reports that nearly 36% of respondents identified “not enough exercise” as a pressing health issue in the community. Resources and services in the Greater Plymouth community that are trying to address this scarcity include the following:  Ninth State is a small fitness complex in Plymouth that offers popular exercise programs like boxing and spinning, as well as dance classes. Due to the cost of membership and the limited facility space, it does not meet the needs of the whole community. Speare RehabFit was also mentioned as a valuable new addition to the service area, although membership dues again limit accessibility. Community members noted that both the pool at Plymouth State University and a motel pool off exit 27 are open to the public. The community spoke with great anticipation and excitement for Plymouth State University’s Athletic and Wellness Center development project, which plans to bring an indoor track and pool, turf field, and wellness and research center to the town. It is likely that the community-at-large will have the option to pay to use these services. Several community members and leaders identified the PSU Ice Arena as an important facility for promoting physical fitness.

  

Even more so than the Plymouth area, Newfound residents suffer from a profound lack of indoor fitness options. With the only exercise program in town now closed (Curves), resident’s closest
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option for a fitness center is the Planet Fitness in Belknap. In recognition of this deficit in services, local organizations are offering the following services:  Tapply Thompson Community Center is currently running a Biggest Losers fitness program called “Newfound Losers”. The community has expressed great interest and enthusiasm in the program with a 2010 enrollment of 144 participants who lost a combined weight of 1,025.25 lbs. Tapply Thompson runs three sessions of Biggest Loser each year, for 12 week sessions. Since the program began, Newfound Losers participants have lost a total of over 5,000 lbs. Additionally, Tapply Thompson runs a twice weekly exercise class that 20-30 people attend. The 1.7 mile multi-use walking path in the Newfound area is a useful all-year round fitness resource for residents. Revitalization plans are in progress to make Bristol downtown a more walkable community. The Newfound area has recently enhanced some of its outdoor recreation areas including Kelly Park.

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In the schools, the teachers and administration comment that increased demands on scholastic achievement have led to reduced recess and physical education time. All of SAU 4 shares just one full-time and one part-time physical education teacher. Fourth and 5th graders at Bristol Elementary school no longer have recess and only have physical education once a week. One initiative to address this change in school programming is development of safe walking routes to school in Bristol and development of a walking track at a local park.

“Physical education is not made a priority in the school system. The students are only getting 45 minutes of physical education a week; however, the national standard is 60 minutes a day.”

The community expressed a strong desire for a large indoor fitness center. When asked what they would spend $2 million for the community on, most community leaders said a fitness center. Some other suggestions to foster active lifestyles include the following:      One leader suggested the inclusion of a fitness membership reimbursement program for HealthyKids subscribers, as well as subsidizes or incentives for eating healthy food. Several leaders noted the need for an exercise and activity space for elders in the Newfound area. Parks and playgrounds in the area should be better designed for younger children, and more strategically placed playgrounds should be added to the community. A Plymouth resident suffering from chronic pain expressed a desire for personal training services to help manage the pain with exercise. Financially and geographically accessible outdoor activities such as neighborhood parks and gardens and low-cost skiing would be potentially valuable assets to the community.
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Healthy Eating: Lack of good nutrition and nutrition education was the other major factor identified by leaders as a cause for the overweight and obese population and was identified as a pressing health issue by 34.7% of the community survey respondents. The Bristol area used to have a WeightWatchers, but since closing residents have to commute to Plymouth to attend WeightWatchers meetings that help them stay on target with healthy eating behaviors and weight loss goals. A Plymouth area resident reported that Ninth State offers a “Weigh to Go” weight loss class on Mondays. Additionally, the nutrition of the senior population is of concern to some service providers. Many of the area’s older adults, in particular widows, rely on a local senior center meals and meals on wheels for one nutritious meal a day, and are unable to provide well-balanced meals for themselves at other times. “There is something so unfamiliar [to parents] about utilizing good foods.” –social service provider

The school systems and youth programming are described as making good progress in efforts to offer more nutritious food, although some contend that the school meals are still too focused on convenience and speed of preparation rather than nutrition. For students on subsidized meals and/or those that have breakfast at school, the nutrition of these meals is important for the student’s brain development. School administrators are reporting higher rates of students with Type II diabetes, which also has implications for the meals offered to students. Community leaders note the critical need to educate both adults and youth about healthy eating habits. Many identified this lack of health education, as a bigger driver of poor diets than income or time. A faith leader noted that people need to be taught how to take personal responsibility for their health. Unhealthy eating and cooking habits affect the whole family. Social service providers report that many families find it difficult to take the first step in “We need to help the community learning how to cook healthy meals. They find comfort in packaged, familiar foods. Budget cuts are a barrier to understand the role of school offering this much needed health education to students nurses. In tough economic times, and families. A school administrator expressed frustration the nurses are sources for more with the school budget committee’s ongoing attempts to than regular care. They are the cut funding for a health teacher and school nurses. children’s doctor.” –school administrator The service area has several innovative programs to bring healthy meals into the schools and back to the homes. Some of those services and initiatives include the following:   The Newfound area schools continually submit grants for funding to build healthier school lunch menus. Danbury Elementary School is running a Crock Pot Program where students assemble meals and bring them home in crock pots for family dinners.
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Wal-Mart and the Food Bank have implemented a “Backpacking Program” that sends students home with meals in backpacks. Newfound High School is running a cooking club for students. The Newfound Regional High School now offers dinner to students once a week, and healthy snacks every afternoon. Tapply Thompson Community Center has removed all vending machines and provides low calorie snacks and 100% juice drinks. Gardening groups, such as the Master Gardeners and ELFS (eco-learning farmstead), are working to create a family-friendly, active and nutritious environment. In addition to WIC and food stamps some NH initiatives helping to make food affordable for service area residents include the following:  NH Food Bank and Catholic Charities support the Newfound area’s lunch programs.  Bristol Shop & Save plays an active role in the community and sponsors school and community events.  United Way (formerly Whole Village Family Resource Center) provides subsidized groceries to families.  The Plymouth Senior Center provides 50-60 meals in its dining hall each day and another 150 meals on wheels out in the community. Nutrition Connections provides cooking lessons with parents and children at various locations. The program also does individual outreach to get to parents who may have a hard time taking that first step.

While many new programs in support of healthy eating have begun in the past few years, leaders had several ideas for future programs that could address the need for healthier diets including the following: A health food store and restaurant could be opened at Boulder Point to compliment the new Speare RehabFIT.  An “Overeaterers Anonymous” group for the Newfound area residents could be established for those in the community in need. “I know the difference when Dental Care: Fifty percent of respondents on the CNHHP someone has lost their smile Community Needs survey identified access to dental care as a because of their teeth.” pressing issue in the community. There were mixed opinions on the capacity of the dental providers in the area. One dental provider noted that with seven dentists in the area, there should be plenty of capacity to serve the residents in the Plymouth area. Others described difficulty getting dental appointments, even with dental insurance. Many identified an unmet need for oral surgeons and orthodontic care. Not only are there a limited number of dentists in parts of the service area (and none in the Newfound area), but very few offer dental services to patients with Medicaid or without insurance
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coverage. A dental practice co-owner interviewed noted “I can’t eat sweets, because there that there is only one dental facility in the area that accepts Medicaid. Dental practices are reluctant to accept Medicaid, is no money to go to the dentist.” because of extremely low reimbursement rates and strict – as told by a child to a local parameters on the dental services that can be provided. A service worker dental practice co-owner commented, “We would like to hook up with the hospital to get full reimbursement [for Medicaid patients]…A $250 extraction now only gets $80 in Medicaid reimbursement. Medicaid [only] does initial exam, x-rays and extractions.” The co-owner gave the example of a mentally ill patient on Medicaid whose condition made regular dental cleanings important, but the service was not covered by Medicaid. Furthermore, Medicare doesn’t cover any dental care except injury to “sound and natural teeth”. The co-owner also reflected on the unfortunate situation of disabled clients who age out of HealthyKids and are no longer eligible for comprehensive dental coverage. Children on HealthyKids insurance are able to get preventive dental care, but many apparently still do not get the preventive care they need. A school administrator noted that several of his/her 7 year old students needed tooth extractions this year. For youth not enrolled in HealthyKids, the cost of dental care without insurance is very often cost prohibitive. Even tooth extractions are a significant financial burden for many residents. In some cases, noted a local service provider, residents need to make the choice between paying for heat or paying for dental care, and during cold winters they are likely to choose the heat. A community leader noted that a reason for low dental insurance coverage rates is that there aren’t large enough employers in the area to support employee dental insurance programs. It was commented that even though Wal-Mart provides dental insurance, the co-pays in the plan make dental care not affordable for its employees. Additionally, no dentists are reportedly available on a 24/7 emergency basis. Residents with emergency dental care needs are typically directed to the Speare Memorial Hospital Emergency Room where they are treated for pain until they can get in to see a dentist. The community noted several initiatives providing dental care to school age children but were unable to identify many dental programs to address adult dental care needs. The initiatives noted include the following:  There is a Plymouth dental hygienist who does dental hygiene practice trainings for primary care, as well as does work in the school systems.

“We just had an incident because dental is not covered. He is on Medicare and dental is not covered…He had teeth to be removed. [It was] not covered and it slammed the family so hard, and it was like ‘Oh my God! What do we do?’” –Ashland female
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Several communities provide school based dental examinations and cleanings. A Newfound area nurse conducts dental screenings in the schools on a regular basis and refers students to dentists. The Bridge House, a local shelter, tries to identify a “Floss Boss” who is responsible for checking that clients are flossing their teeth. A focus group participant shared that adults can get free or reduced rate dental care from dental students at NH Technical Institute. There used to be a dental task force, but it was described as “talking in circles for years deciding what to do”.

Recommendations for improvement of the dental care system include the following:   Local service providers should develop a rotation of dentists willing to do community service and examine local kids that have never been to a dentist before. The Emergency room should be staffed with a dentist. One leader notes that drug abusers frequently have serious dental problems, and when the only treatment option for them at emergency rooms is painkillers it can have devastating consequences. A dental provider recommended a dental insurance pool that provides funding for the poor and uninsured in need of dental care. The insurance pool would be for residents in-between getting insurance from employers, but who don’t meet the eligibility criteria for Medicaid. At a minimum the pool would fund fillings and extractions.

Mental & Behavioral Health: As shown in the survey response summary, 34.4% of survey respondents identified “access to mental health care” as a pressing health issue. Over 37% and 34.1% of respondents noted “adult alcohol and drug use” and “youth alcohol and drug use” respectively as pressing health issues. During the parent focus group, numerous community members noted their reliance on Genesis Behavioral Health services, and described a fear of budget cuts restricting their access to services. Focus group participant’s comments on mental health services include the following:  A Plymouth resident said, “I go weekly [to Genesis]. I mean it just really helps. Especially people who go through tons of grief and transition. To hear they [Genesis] are getting a 50% budget cut…People already can’t afford the co-pay.” A male resident from Lincoln added, “Up in the Lincoln-Woodstock area, it’s a small community, but there is no real mental health providers. It’s not really an impoverished area, but a lot of people are probably living close to the poverty level. It’s seasonal employment, so no one is getting any benefits. And there is no mental health. And I know with the economy the way it is people are just living season to season and there is a lot of stress there, but there is no way to really to cope with it.”

While noting the valuable role Genesis Behavioral Health play in the community, community members and leaders describe a need for other types of mental health services such as psychiatrists,
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licensed alcohol and drug counselors, emergency mental and substance use treatment services, and outpatient mental and addiction services. Expansion of mental and behavioral health services is an important focus for the area, with higher than state average youth alcohol and substance use rates, and high rates of hospitalization and ER visits related to mental health conditions. Community leaders also noted that depression is a prevalent mental health condition in the area. One youth “Access to mental health care is not anywhere near where it should be. Even those with insurance and jobs are reluctant to seek out mental health care they might need because they know that they might only be able to go for eight sessions [before their coverage runs out].” –faith leader service worker said that children at their organization with depression issues don’t get the services they need, because a) they don’t have health insurance, b) can’t access the services, or c) don’t know how to start handling the problem. Many leaders spoke of the capacity deficit for mental health services in the area:  “Mental health is a huge deficit. We have students all the time that need substance abuse and mental health treatment services. For those that need treatment, there is nowhere to go. The closet is Laconia and Plymouth.” Some leaders noted that there are no psychiatrists in the area. Others thought that there are psychiatrists in the area, but that there are none that accept Medicaid or have a sliding fee scale. A local police official described the lost time and “If you went to a hospital and frustration of navigating a suicidal or unsafe resident you thought you had sprained through the medical system. The official described your ankle…would they have said waiting for up to 12 hours and 13 hours on the last ‘no, we don’t treat sprained two cases at Speare Memorial Hospital waiting for ankles. Go away.’ … I just feel like someone that could evaluate the resident’s mental the standard of care is different health status and admit the patient to the State for mental health, and it might Hospital. not be if there was a psychiatrist It was noted that there aren’t enough mental health available in the community.” counselors available in the community and that they aren’t accessible to families without the school system stepping in. Additionally, for those with insurance only 5 sessions are covered, which doesn’t meet the counseling needs of the family. Several community members and local leaders pointed out that it is harder to get anonymity when seeking mental health services in a rural community. Several noted seeking care in other communities so as to be more discreet.

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A faith leader described the challenges one parishioner faced in getting a video-conference psychiatric evaluation. It was noted that it seemed like requesting a tele-medicine evaluation was a difficult hurdle for an individual suffering with mental health problems to address on their own. Having family advocates was essential to pushing the hospital to set up the telepsychiatric session. It was also noted that the tele-medicine felt disconnected and that the patient was not getting the level of care needed.

Co-occurring diseases and disorders such as mental health conditions and substance abuse are similarly lacking in capacity. On the issue of substance use, community leaders note the following:   “From what I’m hearing from the schools, drug use (especially marijuana) is on an up-swing, and with earlier age of onset in middle school.” A school administrator noted that it is nearly “My daughter had gone to {a drug impossible to find a Licensed Alcohol and treatment provider}and she owed them Drug Counselor to work at the local schools money. And they kept saying ‘well you’ve and that the students are in great need of got to pay this’. She doesn’t have any prevention and early intervention services. money and I certainly don’t have any to Prescription drug use is increasing across the give her. So because of that she got no service area, particularly among young adults. A help and she went back down here and home health worker noted that young adults back to her old tricks.” are raiding their grandparents medicine –Plymouth female cabinets. Older adults have many prescriptions that they are not using but don’t know how to dispose of. Smoking, it is noted, continues to disproportionately affect the low socioeconomic populations. One service provider noted that her clients use smoking as a dopamine fix to self-medicate. A local prevention worker noted that there is an increase in alcohol poisonings in the area. Plymouth and Easter Seals rehabilitation centers are always full, and Webster place does not accept health insurance, so there are many residents in need of addiction treatment services that cannot access it. On detox and mental health services, a Plymouth resident commented, “…The detox is a whole 30 days. I’m sorry, but my daughter needs more than 30 days…There is nothing around here “If we don’t get the drugs, alcohol that can handle both mental health and substance and smoking under control then abuse services simultaneously.” down the road these people will A local leader said, “When I talked to an area have multiple, multiple problems.” provider a while ago, they had a two month wait period [for addiction services]…If a young mom comes in for financial help and I can tell by looking at her that she is using methamphetamines, I’d like to be able to say to her ‘here is a check for the grocery store
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AND also can I help you make an appointment with an addiction center…There is nothing now except sending her to AA… or Narcotics Anonymous.” One person noted an inability to find an open short term detox program for his brother. It was noted, “So here he is a year later and hasn’t done anything…it doesn’t sound like a solution to me.”

Several initiatives for expanding mental health services were identified by the community leaders:  The Center for Adolescent Health out of CHAD and Plymouth Pediatrics and the Adolescent Treatment Initiative (ATI) are working to change the mental health delivery system and working to support care management that is: timely, patient and family centered, integrated with other aspects of health care, evidence-based, when feasible, and outcomes driven. The new therapist at Mid-State Health Center is seen as a great addition to the health center, and many wish the therapy services were accessible to non-MSHC patients or that comparable services were available elsewhere. CNHHP is undertaking an initiative to bring in a family clinician from Family Strength. This is seen as an important step in bridging the gap between primary care and mental health. Step by Step is a new program providing early mental health services to 0-3 year olds and their families. Parents are more willing to participate since it is seen as something for their child. Newfound and Plymouth High Schools are increasing school-based support services with additional counselors, social workers and a high risk youth team. There are ongoing initiatives to connect the homeless population with mental health services. Rather than holding meetings to discuss the health issues of individual students, school teams and providers have been engaging in collaborative discussions about how to address public health and medical and mental health issues such as suicide prevention and youth homelessness. The area has also recently started a mental health court-in three districts in the county, but the service is not available yet in Alexandria’s district court. An ongoing focus on the medical home will aid people hesitant to seek mental health services due to the stigma around mental health issues. An individual will go to the same place for care regardless of whether it’s for a primary care visit or therapy appointment. A focus group participant noted that Grace Counseling, a pastoral psychotherapy practice at Plymouth Congregational Church, offers affordable care to patients on a sliding fee scale. Faith leaders noted that the chaplaincy program at the hospital is a relatively new (2.5 years) program that serves approximately 40% of those admitted to Speare Memorial Hospital. Eight local clergy volunteer to visit with patients interested in speaking with someone from the faith community. It was noted that other more developed chaplaincy programs include
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notes from the chaplain’s patient visit in the patient chart to provide a well-rounded patient record. Additionally, the following substance use prevention and treatment services were identified:      NANA provides educational materials for the public on how to dispose of leftover medications. The Newfound area is holding community discussions and parent education classes around substance use. A few years ago, Bridge house clients started an early morning Alcoholics Anonymous meeting, which is now attended by a number of community members. A drug court program has started in Grafton County, which provides alternative sentencing for non-violent drug offenses. The Alexandria police department is hosting a drug take back day (D-Day) at the local transfer station. Residents can drop off old and unused drugs that the VA will pick up. Without the VA as a resource for drug disposal, the police department would be unable to do any drug collection. A service provider noted that, “Over the past two years regionalization of the prevention system has been big for our community, and gets more information out there. It continues to grow.”

Some suggestions and recommendations for improving the mental and behavioral health system in the area include the following:     The community should invest in a substance abuse residential treatment facility for youth in the area. The local health services should partner with Dartmouth-Hitchcock to bring in psychiatry residents to provide services in the area. There should be more collaboration with physicians to curb redundancy in prescriptions and the corresponding abuse by residents. There should be a regional version of 2-1-1, or a regional care coordination call center to connect people with 24/7 mental health and substance abuse treatment services. o Faith leaders noted that they are often the first people to learn about a resident’s mental health or substance use problem, and they want to feel confident in knowing how to connect that individual to appropriate services.

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Elder Care: Limited capacity for elder care is an ongoing concern for the service area. With a proportionally high elder population, it is important to consider the needs and gaps in services for this population. Some of the gaps in services identified included the following:  With limited options for assisted living in the area, many families are caring for their older parents and grandparents. Community leaders note a lack of respite services for adults in this situation. They express a need for more support systems such as transportation and day care programs.  A hospice service provider added that there should be more support available for end of life care.  There is an ongoing and growing need for long term care and assisted living.

Access & Quality of Care
Access to Care: When asked to rate access to care on a scale of 1 to 5, most community leaders and members gave it a rating of 3, with the next most frequent rating being a 4. Health insurance coverage directly impacts an individual’s ability to access care. With a high uninsurance rate of 18% in the service area, access to care is a serious problem to address in the community. Additionally, access to health care is affected by many other factors including: quality of insurance coverage, availability of necessary services or technology, capacity of service providers, flexibility of hours of care and transportation. When speaking of access to care almost every leader gave the qualifier “for a rural community”. ‘For a rural community’, they said, ‘access is good and the health services are progressive.’ Again the issue arose over the “haves” versus the “have-nots”, and how poverty in many ways becomes a barrier to timely and affordable access to care. In the Newfound area, it was reported that only two family practitioners accept Medicaid patients, and in Plymouth it was reported that it’s hard to find providers accepting new Medicaid patients. Throughout the service area dentists refuse to accept Medicaid. “The rural-ness of the community Loss of earnings or even unemployment is a serious prevents people from getting where consideration for many parents that need to leave work to they need to go, whether it’s bring their child to an appointment. Often a broken car or transportation related or weather no access to a car prevents patients from making related.” – social service provider scheduled visits. As one provider put it, “The thing that they’d like to do is maybe the thing that they can’t do, because they can’t afford to lose their job. So they have to choose between services for their child and making sure they have food on the table and a place to live, and that seems not right.”
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In general, community members discussed frustrations with long rides to services not available locally; long wait times in the waiting room; and some miscommunications with pharmacies. Some of the existing services and gaps in services considered when rating accessibility include the following:  Community leaders and the community-atlarge feel very comforted by the emergency “Anyone that wants to get helicopter services. Numerous leaders said it healthcare is going to get it on an made them feel more comfortable seeking care emergency basis, but regular dayat Speare Memorial Hospital knowing that they to-day care is much harder to could be airlifted to Dartmouth or another access.” hospital if special care was needed. The Community Care (NH Health Access) program provides financial assistance in accessing care in the community, including emergency care, gynecology and prescription coverage. When mentioned during the community focus group, only 3 of the 18 participants were aware of the program. Access to specialty care, such as orthopedics, cardiology, oncology, and neonatal care, is limited but has improved over the years. Also, relationships with larger health care facilities like Dartmouth and visiting specialists make it easier to access specialty care.

•In conversations with the general public, it became clear that there are potential issues around lack of information regarding what services are available in the community, as well as expectations regarding the type of resource-intensive specialty services that can be adequately supported locally. When thinking about the variety of care accessible to them, community members said the following:  Plymouth area residents feel there are good alternative medicine practices, such a chiropractic, available in the community but that services are often times cost prohibitive because insurance does not cover it. In the past year, Plymouth hosted an alternative medicine fair.  The Newfound area feels that there is not access to alternative medicine in their community.  One leader noted, “I feel like there is so much out there, and yet I’m constantly meeting people that don’t know what is available or don’t take advantage of it.”  Some Newfound residents view access to the three regional hospitals in Plymouth, Franklin and Laconia as an asset to the community, allowing patients to have more choices for care. Others express a desire for a hospital in their own community.  A leader expressed concern over new regulations that require more steps for a physician to refer a patient to home health care, which may result in decreased access to home health services for needy patients.  Community members are in strong support for early intervention programs, such as Lakes Region Community Services. They noted that such services are extremely valuable resources to them as parents. Many wished services continued for longer into the child’s development.
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The culture of poverty is another issue that some perceived limited access to care. The culture is one of Yankee Pride, and this community has difficulty navigating the system. On the “culture of poverty”, interviewees and focus group participants make the following comments:  “Either it is a pride issue or an awareness issue, but so many people don’t seek out services when they need it- and that’s all types of services: medical, mental…”  There are several new roles helping to provide care coordination and family support to community members including a support specialist at Mid-State Health Center and family services coordinator at Lakes Region United Way (formerly Whole Village Family Resource Center) that provides care coordination services to patients and providers, such as helping with transportation and housing. Access to medical devices and prescriptions is also a challenge for many residents. Even with insurance, prescription co-pays can be cost prohibitive, or travelling to the closest pharmacy may be a challenge for some immobile populations. On access to prescriptions, community leaders and members note the following:  Access to medicine has increased with the development of a Rite Aid in Bristol.  One leader summarized accessibility for elders as follows, “Seniors have three main cost concerns: FOOD-FUEL-MEDICINE. I think pills are purchased last when a senior has to make a financial choice between the three.”  Older adults struggle to afford medical services. An elder services worker noted, “There isn’t enough insurance to cover the health of our seniors, in particular dental care. Teeth are the biggest problem I see.” He also noted a huge problem with affordability of hearing aides and vision care, noting “It is out of the elder’s range.”  The Prescription Card is a new program in the community that partners with large scale pharmacies to offer reduced cost prescriptions to the uninsured.  Community Care (NH Health Access) also offers a prescription program. Of that program a local resident exclaimed, “If it weren’t for them, my husband would probably be dead… I have never been more grateful for anything in my life.” Community leaders shared the following recommendations for improving access to care:  The region could implement a MediBus that picks children up at school for well-child visits.  A local physician commented, “Looking at friends and family that have cancer, it would be nice to have radiation and oncology locally available. It’s a challenge to have to drive to Hanover for treatment so often.”  The local school administrators said they want to support the community in any way they can, such as by hosting well-child visits at the schools on Saturdays.  One leader would like to see a HealthCare for Homeless model implemented in the local shelters that include visiting psychologists and nurse practitioners.  Telehealth was mentioned by some as a potential tool to increase accessibility, but with notes of skepticism. Several leaders feel that telehealth may further isolate rural residents and depersonalize their care. Additionally, those that are most disenfranchised are the least likely to take advantage of the telehealth, because they don’t have the patterns of behavior to know naturally where to go and how to access services.

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Quality of Care: When asked to rate the quality of health care in the community on a scale of 1-5, the most popular answer was “4” followed by 5 for excellent quality of care and 3. Similar to access, leader’s measures of quality were tempered by the rural nature of the service area. Some of the leader’s thoughts of quality include: 

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“A town for our size and location has a very progressive hospital with progressive services.”  Additionally, a community leader noted, “We are very lucky to have what we have, even if it is understaffed “Several years ago, I sometimes.” wouldn’t have gone to  One leader added that when the hospital is unable to afford Plymouth for any life something such as an MRI machine, they bring it in weekly for threatening issues. I patients. would have gotten  Said a community leader, “The physicians seem to care as much myself in the car and about the community as the rest of us.” gone somewhere  One member of the medical community proposed that “Primary else.” care [in the service area] is awesome, and is as good or better than the rest of the state.”  A local social service provider exclaimed, “It is incredible what everyone is doing with the available services. Genesis has divided its people into two! The reason I would scale it down from 5 to 4 is the lack of dental services.”  Several leaders noted that the new facades at MidState Health Center and Speare Rehab Center, as well as “In my personal experience as community bulletins and news updates, help prevent any a nurse and with a partner perceptions of services being rural or basic. who is a physician, Plymouth  Several noted that Mid-State Health Center’s move has a very forward thinking to Boulder point with the Rehab center increased hospital…that has been integration of services and was more “holistic”. implementing best practices  One health care provider noted that the service area for years.” is a very hospital oriented community, and that quality of care could benefit from moving more towards care at physician’s practices and medical homes. Another medical director added the medical homes need to be established “so nothing is forgotten or left behind”.  People with chronic conditions are continually readmitted to the hospital because there isn’t appropriate care coordination after a patient is released from the hospital.  The service providers’ medical records don’t speak to each other currently, because they all use different vendors. In order to improve care coordination, medical record systems should “be like ATMs” where you can access information regardless of the company.
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Many leaders note the challenges of recruiting and retaining doctors in the community, because of lack of employment options for their spouses, lack of urban amenities such as shopping malls, and inability to offer competitive salaries. Health service providers like Mid-State Health Center and Speare Memorial Hospital are seen as taking good steps towards making employment with them and in the community more desirable. For example, Mid-State Health Center added a Montessori school within its building so medical staff can have their children close by. Health education is recognized as an important part of high quality of care. Similar to preventative care, health education helps prevent risky behavior that may lead to health issues in the future. The challenges of getting people to participate in health education programs include the time commitment of attending programming outside of business hours and the potentially long drive for those outside of Plymouth. Workplace wellness programs were one identified strategy for reaching residents with health education, since people are less motivated to attend programming outside of business hours. For example, PSU’s 400 employees are provided wellness programs, incentives, and cash-back for participation in wellness activities and events. Some other initiatives mentioned by the leaders that are addressing quality of care are:     Establishment of an accountable care organization to focus on positive outcomes for illnesses and reduced costs. One leader noted how unique it is to have doctors in the area that still do home visits. The Newfound School system is putting together a community health fair. Several leaders noted the benefit to the community of having the new therapy pool and water exercise programs at Pemi-Baker Community Health.

Suggestions for addressing any gaps in the quality of care include the following:   The delay between intake and start of services for mental health patient’s needs to be quicker. Health care providers should continue to bring health care to the people, rather than expecting them to always come to the providers. This can be accomplished through things like community based immunization and flu clinics. Providers can develop recognition and incentive programs for patients that engage in a healthy lifestyle. Encouraging development of more private practices, with doctors not working for fee-forservice was noted as ‘something to be desired’. Continue to focus on development of medical home so patients can have “one stop shopping” and “don’t have to be referred out of their comfort zone.”

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How to Use $2,000,000: Community members and leaders were asked if they were given $2 million to spend on any one thing that would contribute to improved health in the community, what they would spend it on. The following table compiles their responses.
Figure 38. Category of Services & Amenities Mental & Behavioral Health Services How Community Leaders Would Use $2M

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 Hire LADC (Licensed Alcohol and Drug Counselors) to “get on top” of substance use issues in the school system.  Increase access to and capacity of mental health services.  Increase mental and behavioral prevention services.  Several community leaders said they would build an indoor sports and wellness center.  Build an outdoor community center with a challenge course.  Increase access to healthy local food..  Stimulate tourism in the area by making Tenney Mountain Ski Area a year-round resort with a golf course and hotel.  Start a free indoor family activities center.  Implement more options for after school programming.  Build a new facility for Tapply Thompson Community Center that includes a pool and exercise room.  Make a large events venue.

Active Living

Healthy Eating Economy Community/Activity Center

Housing

 Build a housing option for homeless veterans.  Implement more transitional living programs.  Build more affordable housing.  Build playgrounds for every community.  Improve parks.     Put funding in a trust for long-term planning. Provide microcredit loans or grants to local families in need. Create “love accounts” or endowments for un-insured residents. Create a dental health insurance pool.

Outdoor Spaces Charitable Trusts & Microcredit

Early Learning Transportation Health Information Exchange Dental Care

 Ensure funding for HeadStart.  Open a full day learning center and extended day kindergarten program.  Implement a transportation model like Center Harbor.  Two community leaders want to invest in a health information exchange.  Several community leaders want to improve dental care and increase capacity.  Create a dental health insurance pool for uninsured. Community Health Institute 73

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1 America’s Health Rankings, United Health Foundation; 2010. 2 Institute of Medicine Committee on Using Performance Monitoring to Improve Community Health, Improving Health in the Community, A Role for Performance Monitoring. 1997, Washington, DC: National Academy Press. 3 Evans, R., M. Barer, and T. Marmor, Why Are Some People Healthy and Others Not? 1994, New York: Aldine De Gruyter. 4 2005-2009 American Community Survey 5-year Estimates 5 2005-2009 American Community Survey 5-year Estimates 6 US Census 2000 7 US Census 2010, SF1 8 Bureau of Labor Statistics, Local Area Unemployment Statistics Data, Updated 2011: http://www.ers.usda.gov/data/unemployment/RDList2.asp?ST=NH 9 2005-2009 American Community Survey 5-year Estimates, (90% margin of error) 10 North Country Council-Transport Central, Nelson/Nygaard consulting associates. Transit Feasibility Study: Draft Final Report, September 2010. 11 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 12 Behavioral Risk Surveillance Survey, 2004-2008 Note: Data represents Grafton County geography.
13

NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 14 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009. 15 2005-2009 American Community Survey 5-year Estimates 16 2005-2009 American Community Survey 5-year Estimates 17 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 18 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 19 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2003-2004-2005-2006-2007]. 20 NH Division of Public Health Services. 2011 New Hampshire State Health Profile 21 United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Compressed Mortality File (CMF) on CDC WONDER On-line Database, 2007 22 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 23 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Dartmouth Medical School. New Hampshire State Cancer Registry, 1997-2007. 24 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography.

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25 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 26 ibid 27 McCormick MC. The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine. 1985; 312(2): 82-90. 28 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 29 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Preventing Smoking and Exposure to Secondhand Smoke Before, During, And After Pregnancy. October 2, 2007; http://www.cdc.gov/NCCdphp/publications/factsheets/Prevention/smoking.htm. 30 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2008]. 31 CDC MMWR. Trends in Smoking Before, During and After Pregnancy—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 31 Sites, 2000-2005, http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5804a1.htm, [2005] 32 NH Division of Public Health Services. 2011 New Hampshire State Health Profile 33 NH Division of Vital Records Administration Birth Certificate Data, 2008. Accessed from NHHealthWRQS 10/2011. Note: Data set includes the town of Canaan, which is not part of the service area and is missing the towns of Waterville Valley and Wentworth. 34 NH Division of Public Health Services. 2011 New Hampshire State Health Profile 35 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 36 Centers for Disease Control. National Center for Health Statistics; http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_16.pdf 37 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2008]. 38 Institute of Medicine. The Future of the Public’s Health in the 21st Century, Washington, D.C.: National Academies Press, 2002. 39 Centers for Disease Control, National Childhood Blood Level Surveillance Data (2007); http://www.cdc.gov/nceh/lead/data/national.htm 40 Centers for Disease Control and Prevention. Blood Lead Levels--- United States, 1999-2002. MMWR Weekly. Vol 54; 2005: 513-516. 41 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009. 42 2005-2009 American Community Survey 5-year Estimates 43 New Hampshire Immunization Program, Grafton County 4:3:1:3:3:1:4 Rates, 2010 44 US, National Immunization Survey, Q3/2008-Q2/2009 Note: US rate confidence interval equals +/- 1.2 and NH rate equals +/- 5.9. 45 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011. 46 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011. 47 NH 2008-2009 Third Grade Healthy Smiles-Healthy Growth Survey

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48 Obesity Prevention Program, NH Department of Health and Human Services, Division of Public Health Services. Dec 2010 Childhood Obesity in New Hampshire, 2008-2009 49 Martin TA, White C, Van Dole K. The New Hampshire Health Assessment Project. NH Dept. of Education, 2003. 50 Martin TA, Helping NH’s Children Become Their Physical Best. NH Medical Society Annual Meeting November 2004. 51 New Hampshire Department of Health and Human Services Division of Public Health Services, Bureau of Population Health and Community Services Obesity Prevention Program. New Hampshire Obesity Data Book, 2010. 52 Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website. Retrieved 11.24010 from www.nschdata.org 53 Eaton D, Brener N, Kann LK. Associations of health risk behaviors with school absenteeism. Does having permission for absence make a difference? Journal of School Health. 2008; 72(4): 223-229. 54 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 55 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011. 56 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration Death Certificate Records, [2004-2007]. 57 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2003-2007.
58

NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 59 New Hampshire Department of Health and Human Services Division of Public Health Services, Bureau of Population Health and Community Services Obesity Prevention Program. New Hampshire Obesity Data Book, 2010. 60 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 61 NH Dvision of Vital Records Administration Death Certificate Data, 05-07 62 HRSA, Bureau of Primary Health Care, 2010 63 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2010 64 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 65 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 66 NH Division of Public Health Services. 2011 Snapshot of New Hampshire’s Public Health Regions, Counties, and the Cities of Manchester and Nashua. Note: Data represents the Greater Plymouth Public Health Region geography. 67 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2006. 68 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011. 69 Behavioral Risk Surveillance Survey, 2008. 70 National Survey on Drug Use & Health, 2004-2006. 71 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, Division of Vital Records Administration, [2006-2007-2008]. 72 Healthy NH Leadership Council.

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73 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009. 74 National Survey on Drug Use & Health, 2004-2006. 75 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), and the New Hampshire Department of State, NH Hospital Discharge Data Collection System, 2003-2007. 76 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009. 77 CDC Injury Center Media Relations. CDC Study Finds Seat Belt Use Up to 86 Percent Nationally, 4 Jan 2011. 78 New Hampshire Department of Health and Human Services, Division of Public Health Services. New Hampshire State Health Profile, 2011. 79 New Hampshire Department of Health and Human Services (NH DHHS), Bureau of Public Health Statistics and Informatics (BPHSI), Health Statistics and Data Management Section (HSDM), Greater Plymouth Public Health Region Data Profile, 2008-2009. 80 CDC Injury Center Media Relations. CDC Study Finds Seat Belt Use Up to 86 Percent Nationally, 4 Jan 2011. 81 North Country Council-Transport Central, Nelson/Nygaard consulting associates. Transit Feasibility Study: Draft Final Report, September 2010. 82 A Picture of Subsidized Housing, 2008. 83 New Hampshire Department of Health and Human Services, Bureau of Homeless and Housing Services. 2011 Pointin-Time Count January 26, 2011, 2011.

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Appendix I Community Survey Results
 

CNHHP
Central New Hampshire Health Partnership

APPENDIX I

COMMUNITY HEALTH NEEDS SURVEY EARN $$ FOR A LOCAL CHARITY!
Dear Community Member:  The Central NH Health Partnership is working to collect information about the  health of your community and we want to hear from YOU.   “Your community” can mean different things to different  people. For the purpose of this survey, your community  can be as big as the Greater Plymouth & Newfound area  or as small as your town. Answer the survey questions by  thinking about the area you see as “your community”.   For each local resident that completes the survey, the Central NH Health  Partnership will donate $2 to a local charity in need!  Please take 5‐10 minutes to give us your thoughts and opinions. The survey is  completely anonymous.  You will not be asked for your name or contact  information.    Your opinions on how we can build a healthier community are important!  Thank you very much for your time.    If you have any questions on this survey please call 573‐3341.  A summary report  of the survey results will be locally available.  Thank you again for your help.  CNHHP Partners

 Communities for Alcohol and Drug-Free Youth  Community Action Program, Belknap-Merrimack Counties, Inc.  Genesis Behavioral Health   Mid-State Health Center  Newfound Area Nursing Association  Pemi-Baker Home Health And Hospice  Plymouth Pediatrics and Adolescent Medicine   Plymouth Regional Clinic  Speare Memorial Hospital  Whole Village Family Resource Center  www.cnhhp.org

PARTNERS

COMMUNITY HEALTH NEEDS SURVEY 
1. 

APPENDIX I

ALL SURVEY RESPONSE FREQUENCIES (n=600 completed responses)
What do you think are the most pressing  health issues  in your community today?   (Check up to 5)     34.1%  Youth alcohol & drug use  50.2%  Access to dental health care    37.5% Alcohol & drug use  34.4%  Access to mental health care    25.3% Smoking/tobacco use  32.4%  Access to primary health care  Access to specialty services  8.5%  Please specify:  _____________________  39.2%  Access to enough health insurance  18.0%  Health care for seniors  Mental illness  33.7%  (depression, anxiety, etc.)  7.8%  Alzheimer’s  11.7%  High blood pressure/heart disease  12.9%  Diabetes  34.7%  Poor nutrition/unhealthy food  35.9%  Not enough exercise    13.7% Cancer        4.2%  Asthma  2.0%  HIV/AIDS  5.8%  Sexually transmitted diseases  Other infectious diseases  Prenatal care  Unplanned pregnancy  Teen pregnancy  Other  Please specify:  ___________________ 

  1.5%    4.1%    8.6%    15.3%   6.9%   

 

  TOP 10 Most Pressing Health Issues  1. Access to dental health care   2. Access to enough health insurance  3. Alcohol & drug use    4. Not enough exercise    5. Poor nutrition/unhealthy food    6. Access to mental health care    7. Youth alcohol & drug use   8. Mental illness    9. Access to primary health care    10. Smoking/tobacco use   

 

    50.2%  39.2%  37.5%    35.9%    34.7%    34.4%  34.1%  33.7%  32.4%  25.3% 

         

Most Common Open‐ended Responses to “Access to Specialty Services”  1. More local service options in general (1.5%)  2. Mental health services (1.0%)  3. Transportation (0.7%)    2 of 62

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    2. 
64.1%  21.3%  21.8%  49.0%  15.5%  16.0%  50.3% 

APPENDIX I

    What do you think are the most pressing  safety issues  in your community today?  (Check up to 5)  People under the influence of alcohol    Discrimination based on lifestyle  15.8%  or drugs  choices or race  Crime    11.7%  Identity theft  Youth crime    25.4%  Being prepared for an emergency    Safety at public places  Child abuse or neglect  8.2%  (parks, streets, etc.)  Elder abuse    13.6%  School violence  Rape and sexual assault    49.8%  Bullying/cyber‐bullying    Other  Domestic violence or partner abuse  5.8%  Please specify:  ___________________ 

TOP 7 Most Pressing Safety Issues  1. People under the influence of alcohol or drugs   2. Domestic violence or partner abuse      3. Bullying/cyber‐bullying           4. Child abuse or neglect          5. Being prepared for an emergency      6. Youth Crime              7. Crime               

64.1%  50.3%  49.8%  49.0%  25.4%   21.8%  21.3% 

Most Common “Other” responses for most pressing safety issues  1. Driving/traffic safety (1.5%)  2. Not enough activities for youth (0.5%) 

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APPENDIX I

3.  

What services or resources should we focus on improving to support a healthy  community?  (Check up to 5)  
  23.3%    22.1%    49.8%    31.3%    9.7%    11.4%    8.2%    10.2%    7.3%  Services for persons with disabilities  Substance abuse recovery programs  Access to affordable housing  Access to affordable food  Access to affordable clothing  Clean air and water  Sports and event opportunities  Arts and cultural events  Other  Please specify:  ___________________ 

50.7%  Public transportation  55.8%  Job opportunities  26.5%  Job training  Adult education & learning  22.3%  opportunities  28.9%  Parenting support  25.2%  Quality child care  36.1%  Youth programs and support  21.6%  Education in the public schools  26.7%  Support for older adults 

 

    TOP 9 Services or Resources to Focus on Improving to Support a Healthy Community  1. Job opportunities        55.8%  2. Public transportation       50.7%  3. Access to affordable housing    49.8%  4. Youth programs and support    36.1%  5. Access to affordable food    31.3%  6. Parenting support       28.9%  7. Support for older adults     26.7%  8. Job training         26.5%  9. Quality child care        25.2%      Most Common “Other” Responses for Services or Resources to Support a Healthy  Community  1. Access to affordable health care     1.3%  2. Domestic Violence Education/Support   1.2%  3. Mental Health Support/Resources    0.5%  4. Poverty Reduction         0.5%  5. Jobs              0.5%            4 of 62

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APPENDIX I

4.  

In the past year, have you or someone in your family had difficulty getting the  services you needed?  
  55.5%  No (skip to question 5 on next page) 

44.5%  Yes (continue below)   

4b. If yes, which services did you or your family have difficulty accessing? (Check all that apply; percentages below are of all respondents; n=600)  
  9.3%          6.2%  5.8%  3.0%  5.2%        Social/human service agencies    Drug & alcohol treatment/recovery  services  In‐home support services  Long‐term care  (assisted living or nursing home care) Other  Please specify:  ___________________   

18.0%  Primary health care  7.2%  Specialty health care  Please specify: ___________________ 

6.2%  Dental care for children  23.5%  Dental care for adults  10.5%  Mental health  6.5%  Emergency health care 

Top 5 Services with Experience of Access Difficulties  1. Dental care for adults      23.5%  2. Primary health care      18.0%  3. Mental health        10.5%  4. Social/human service agencies    9.3%  5. Specialty health care       7.2%  Most Common Open‐ended Responses to difficulty accessing  “Specialty health care”   1. Orthopedics   0.5%  2. Diabetes    0.3%  3. Dental    0.3%  Other Services Commonly Mentioned with respect to access difficulty  1. Transportation        0.8%  2. Financial/Eligibility Assistance   0.7% 

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  10.5%  5.3%  4.7%  13.0%  9.7%  8.0% 

APPENDIX I

4c. If yes to #4, why was it difficult to get the services you needed? (Check all that apply; percentages below are of all respondents; n=600))  
Did not know where to go to get  services  Did not understand how to get the  service  Office was not open when I could go  Service I needed was not available  Had no way to get there  Waiting time to receive the services  was too long              21.8%  7.0%  4.2%  24.7%  3.3%  2.5%    0.2%    3.3%          Had no health insurance  Service was not accepting new  clients/patients  I was turned away  Could not afford to pay  Needed help with paperwork  Misunderstanding with staff  Language/cultural barrier  Did not want people to know that I  need the service         

4.5%  Had no one to watch my child  12.8%  I was not eligible for services  Other  6.3%  Please specify: ___________________       

TOP 8 Reasons for difficulty getting services (percentages are of all respondents)   1.  Could not afford to pay            24.7%  2.  Had no health insurance           21.8%  3.  Service I needed was not available        13.0%  4.  I was not eligible for services          12.8%  5.  Did not know where to get services        10.5%  6.  Had no way to get there            9.7%  7.  Waiting time to receive the services was too long   8.0%  8.  Service was not accepting new clients/patients     7.0%        Other Reasons Commonly Mentioned for access difficulty  1. Coverage/eligibility limitations 0.8% 2. No dental insurance 0.7% 3. Travel/distance 0.5%          

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5.  

APPENDIX I

Which of the following programs or services would you or your family use if it  was more available in your community?  (Check all that apply)  
After‐school activities for youth  Childcare  Adult daycare  Parenting support groups                    49.2%  30.9%  34.2%  13.3%  5.0%  6.5%  21.6%  11.1%  9.4%  Fitness/exercise program  Nutrition/cooking program  Weight loss program  Health education  Lesbian, gay, trans‐gender and  bisexual support services  Diabetes support group  Mental health counseling  Drug and alcohol treatment  Drug and alcohol prevention  activities  Stop smoking program  Medical services  Please specify:  ___________________  Public transportation   

28.5%  18.5%  7.4%  13.5% 

16.6%  Family counseling  9.6%  Caregiver support  13.7%  Education workshops for parents  24.8%  Adult education  27.2%  Job training  12.8%  Information and referral  41.2%  Stress reduction and relaxation classes  17.9%  Community gardening  Other  4.8%  Please specify: ___________________ 

  16.6%    7.2%    35.9%     

TOP 6 Programs or Services respondents would use if more available   1.  Fitness/exercise program      49.2%  2.  Stress reduction and relaxation classes  41.2%  3.  Public Transportation       35.9%  4.  Weight loss program        34.2%  5.  Nutrition/cooking program      30.9%  6.  After‐school activities for youth    28.5%  Most Common Open‐ended responses for “Medical Services”  1.   Dental Care          0.7%  2.   Affordable Health Care      0.5%        0.5%  3.   Primary Care    4.   Specialists, in general       0.5%    "Other" Commonly mentioned services respondents would use if more available (open‐ended  responses to question 5)  1.   Dental Care          0.5%  2.   Affordable programs/services    0.5%  3.   Transportation          0.3% 

CNHHP
Central New Hampshire Health Partnership

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APPENDIX I

6.  What do you think is the best thing about living in your community?
472 total comments were received.  The most common theme (approximately 25% of  respondents) regarding the best thing about living in their community is: 
FAMILY, FRIENDS & NEIGHBORS; Helpful People, Sense of Community Connections and Support

See Page 23 for a complete listing of comments organized by major theme 

    7.  What do you think is the most difficult thing about living in your community?
477 total comments were received.  The most common theme (approximately 18% of  respondents) regarding the most difficult thing about living in their community is: 
Lack of Transportation/Public Transportation

See Page 36 for a complete listing of comments organized by major theme          8.   If you could change one thing that you believe would contribute to better  health in your community, what would you change?   414 total comments were received.  The most common theme (approximately 11% of  respondents) regarding the one thing they would change to contribute to better health in  the community is: 
HEALTHIER EATING/ACTIVE LIVING

See Page 50 for a complete listing of comments organized by major theme            The following questions will help us to better understand the characteristics of your  community. This information will not be used to identify you in any way.            9.   What is your age?   1.4%  18‐19    30.3%  50‐64    9.9%  65‐74  8.3%  20‐24  18.2%  25‐34    5.8%  75 and older  26.0%  35‐49      Skipped question=7.6%            10.   What is your gender?   24.3%  Male    75.7%  Female        Skipped question=9.5%   

     

     
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APPENDIX I

    11.   About how many years have you live in the Greater Plymouth or Newfound  area?  
Average number of years respondents have lived in the region = 20.9 years  Median number of years = 18 years  Range: minimum of less than 1 month; maximum of 114 years  26.3% of respondents have lived in the region for 8 years or less  24.7% of respondents have lived in the region from 9 to 18 years  27.1% of respondents have lived in the region from 19 to 30 years  21.9% of respondents have lived in the region for more than 30 years  

 

12.  
5.1%  7.1%  3.6%  12.9%  10.4%  1.3%  0.4%  0.2%  0.5%  2.2%  2.2%  5.8% 

What town do you live in now?  
Alexandria  Ashland  Bridgewater  Bristol  Campton  Danbury  Dorchester  Ellsworth  Grafton  Groton  Hebron  Holderness   
O the r  to wns   mentioned  include:  F r ank l in  (0 .7 %)  H i l l  (0 .5 %)  S and w ich  (0.3 %)  C an aan  (0 .3%)  An dover  (0 .2 %)  C en te r H ar b o r (0 .2 %)  Gilford (0 .2%)  L a c on i a (0 .2%)  M e red i th  (0.2 %)  O s s ip e e  (0.2 %)  Piermo nt  (0.2 %)  Tilton   (0.2%) 

                     

1.5%  2.7%  0.2%  23.1%  5.6%  6.2%  0.9%  0.5%  2.6%  1.1%  3.8% 

   

 

Lincoln  New Hampton  Orange  Plymouth  Rumney  Thornton  Warren  Waterville Valley  Wentworth  Woodstock  Other  Please specify:  __________________   

 

 

 

 

CNHHP
Central New Hampshire Health Partnership

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APPENDIX I

  For questions 13 & 14, a household is a group of people sharing a home and any income  earned with each other.  13.   Approximately, what is your annual household income?     18.1%  $50,000‐ $74,000  16.1%  Less than $10,000    11.9%  $75,000‐ $100,000  19.6%  $10,000‐ $25,000    8.0%  More than $100,000  26.3%  $25,000‐ $49,000          Skipped question=14.3%    14.   How many people are part of your household?   Average number of people in the household = 2.9   Median household size = 3 people  Range: minimum of 1 person; maximum of 13 people  14.6% of respondents have 1 person in their household    33.9% of respondents have 2 people in their household  21.2% of respondents have 3 people in their household  18.3% of respondents have 4 people in their household  12.0% of respondents have more than 4 people in their household   

҉

Thank you

҉ 

CNHHP
Central New Hampshire Health Partnership

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APPENDIX I

Open‐Ended Responses to "access to specialty services" as a most pressing  health issue (Question 1)  Category  Response  More Local  always have to travel  Service  MD's ‐ localize ‐ travel less  Options  Need closer MD's  1.5%  Need local  need locally  No local MD's, transportation.  Nothing local  Oftentimes if a "specialty service" is recommended there may  be only one choice for the family in the area, or none at all,  within a close driving distance.  This is especially true for  mental health services including the often recommended‐  therapy.  Families frequently drive to DHMC, Manchester,  Laconia, Concord, or even Boston for evaluations but  continued care is very hard to come by in the local area.  If there are specialists (ENT, OB‐GYN, cardiology, etc...) in the  community the choices are limited and the quality of the  facilities is limited.      Mental Health  Counseling  Services  Counseling  1.0%  Infant Mental Health Services  mental health and dental  Oftentimes if a "specialty service" is recommended there may  be only one choice for the family in the area, or none at all,  within a close driving distance.  This is especially true for  mental health services including the often recommended‐  therapy.  Families frequently drive to DHMC, Manchester,  Laconia, Concord, or even Boston for evaluations but  continued care is very hard to come by in the local area.  Wrap around services for children with mental illness and  history of abuse but still lives with parents.      Transportation  lack of transportation  0.7%  No local MD's, transportation.  Shuttle bus service for seniors and special needs patients  (wheelchair‐bound citizens) and those who cannot drive.  This is a rural area, and access to any healthcare services can  be a challenge due to lack of transportation for the elderly, 

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APPENDIX I

mentally ill and poor residents within the community.    Cardiology  Cardiology, gastrointerology  0.5%  cardiology, pulmonologist, podiatrist, Decent Orthopedics that  I would be willing to go to.  Female Physicians, vascular  surgeons‐ and even if they were here‐ there is no type of this  surgery here.  If there are specialists (ENT, OB‐GYN, cardiology, etc...) in the  community the choices are limited and the quality of the  facilities is limited.      Dermatology  Dermatology  0.3%  Dermatology & other    Orthopedics  cardiology, pulmonologist, podiatrist, Decent Orthopedics that  0.3%  I would be willing to go to.  Female Physicians, vascular  surgeons‐ and even if they were here‐ there is no type of this  surgery here.  Ortho    Pulmonology  cardiology, pulmonologist, podiatrist, Decent Orthopedics  0.3%  that I would be willing to go to.  Female Physicians, vascular  surgeons‐ and even if they were here‐ there is no type of this  surgery here.  Pulmonary    Uninsured/low  all for the un or under insured  income  community care does not cover special doctors like  services  orthopedic, pain clinic, or physical therapy.  0.3%    Other  Cardiology, gastrointerology  Specialties  cardiology, pulmonologist, podiatrist, Decent Orthopedics that  I would be willing to go to.  Female Physicians, vascular  surgeons‐ and even if they were here‐ their is no type of this  surgery here.  Head injury group  Home care 
My physical therapy was cut off, I appealed but was denied.  I  don't even finish first phase of therapy so it will hurt my condition  extremely.  Specialty services are all outside.  Optometrist  Orthodontics  specialists  Theraputic services 

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Urology  Autism    any service not covered by PCP  Concord, Dartmouth  chinese herbalist  Chronic illnesses and conditions 

APPENDIX I

Other 

    Other Most Pressing Health Issues (open‐ended responses on Question 1)      Domestic Violence (5 mentions)  Domestic Violence  domestic violence, stalking issues  1.2% 
Health issues related to violence in families, DV/SA/CA    Advocacy for disability.  Disability Issues  doctors need to know about laws and requirements about  0.8%  disability  MD's need to know about laws & requirements about  disability.  If you are trying to get on disability, disability requests  mds. in this are nurse practitioners aren't our pcps.  Nurse practitioners be = ? under disability law.    Obesity (4 mentions)  Obesity    0.7%    affordable dental health care  Dental Care  Access to dental insurance for those who don't quality for  0.5%  healthy kids.  dental services    Insurance/Affordable  Development of affordable health care for everyone.  insurance cutoff ‐only allowed so many visits  Care  Not enough insurance coverage.  0.5%    Not enough activities for children during summer.  Youth Activities  Youth activities  0.3%      Transportation  Transportation  Transportation to health care  0.3%    Ability to care for simple conditions and illnesses.  Other  At this point I've had no trouble obtaining assistance in  areas of health issues 

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Birth control ‐ family planning for all.  Head traumas  Health care for homeless  health care options for healthy adults  Lymes Disease  MD's, clinics.  Should be unbrellered with all mass needed  specialty and regular.  Not enough units for therapy.  New patient for doctors.  No parking place for parking on walk.  No sense of personal responsibility.  Nursing Home  Pediatricians need to be educated and willing to refer  children suspected to have neurological disorders, such as  sensory processing disorder.  School lunch sucks.  No more phys. ed!! What are they  crazy?  Too many abortions 

  Other Most Pressing Safety Issues (open‐ended responses to Question 2)      Driving Safety  Aggressive driving  auto safety i.e. unsafe drivers  1.5% 
Cell phones  Drivers who don't pay attention  Driving & cell phones/texting  Driving badly  Driving while texting and cell phone use  Drunk driving  Insufficient enforcement of traffic laws, speeding in town.    Not enough programs for kids.  Not enough recreational activities for children 10 to 18 years old.  Nothing in area for children unless you have $.   

Not enough  youth  programs  0.5%  Mental Health  mental health  mental health patients  0.3% 
  age discrimination  Age  Discrimination  Age‐ism    0.3% 

Other 

Are there emergency plans in place for BiPap and C‐Pap users?   Also O2 users?  at this time i feel that these issues are well in check  Babies unsafe in the womb from abortion.  cyber crimes  Elderly at home when more assistance needed ‐ transportation, 

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APPENDIX I

more assisted living or more insurance coverage for home care  agencies to go into homes.  Insurance  Lack of vision for a future based in mutual respect for our  neighbors, lack of education to understand we are creating all of  our issues confronting us.  mail theft  Neglect of our elderly by their families of origin  Non‐traditional & dysfunctional homes; absent parents.  Not enough sexual health classes for the youth  Not enough sidewalks and no paved walking and biking paths along  roadways  People stealing in apartments all over.  Police hide their heads, not admitting it (drugs).  Proper living conditions due to poverty.  War on Drugs, Foreign Wars, Economy 

      Other Services or Resources to Support a Healthy Community (open‐ended  responses to Question 3)      Access to affordable  Access to affordable health care  Access to Insurance or Alternatives up front.  health care  Affordable access to whatever health care people need.  1.3% 
Affordable health care  cheaper health care system  Free healthcare for low income families.  Health Care  Income limit is low; people with higher incomes that pay for  their health can't get help.    Community education on DV/SA/CA  domestic violence support  DV services  Increased capacity for DV/SV crisis services  increasing capacity of DV/SA/Elder Abuse/Bullying crisis  services  Expanded DV/SA Services  More education to communities about the impact of  Domestic Violence and Sexual assault and how to hold  batterer's accountable in DV and rapists accountable in  Sexual assault cases.    depression hotline service  Mental health, access to care and care. 

Domestic Violence  Education/Support  1.2% 

Mental Health 

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Support/Resources  0.5% 

APPENDIX I

Support for children with a history of mental illness and  abuse who need  government support, but still lives with  parents    Poverty Reduction  Poverty Reduction  Reduction of Poverty  0.5%  Money availability to low income.    Jobs affordable food and housing and public transpo are  Jobs  huge problem areas around this area  0.5%  Jobs that pay a decent salary.  Specialized job availability    More answers to subsidy housing.  Housing Assistance  Programs needed so people that are extremely low income  0.3%  can own a house.    Outdoor activities (walking and bike paths).  Recreational  we need roller skating rinks and bowling and parks for  resources  everybody and indoor and outdoor pools  0.3%    affordable healthy food  Healthy Food  nutrition/healthy food & exercise  0.3%    Autism  Autism  Awareness/Education  That special education teachers and other school staff are  educated in neurological disorders such as sensory  0.3%  processing disorder and autism spectum disorders.    affordable child care  Other  Dental care especially as well as transportation.  Help with disability court.  individual/single person services‐ human services dept.  welfare‐ state financial assistance, financial security  Intergenerational outreach programs would benefit both  elders and youth.  more availability to lower income  More review and re‐determination of disability claims  Pro‐life pregnancy/resource centers.  Something in the Bristol area that will be good for older  kids & also places that will do groups for anxiety.  Vocational training H.S.  We have no need for any of these programs.  There are only  2 adults here. 

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APPENDIX I

Specific specialty health care mentioned with respect to access difficulty  (question 4b)  follow ups for orthopaedics, labs, x‐ray and other diagnostic  Orthopedics  tests, follow up for gastrointestional disorders  0.5% 
ortheopedics  Orthopedics    diabetes  Diabetes, dental    Diabetes, dental  Dentures    A family member is a recent amputee with spina bifida.   Doesn't drive.  There are no specialists in the area which  means over an hour drive for every doctor appointment.   For a low income non driver it's very hard for her to get to  doctor’s appointment due to price of gas and lack of  transportation  A need for the diagnosing, treatment, and education of  neurological disorders such as sensory processing disorder,  and autism spectrum disorders.  affordable eye care glasses  all services above  alternative health care  back pain and expert doctors  cardiology  Chronic illnesses, home care  Chronic, so if I go to ER for acute they won't treat me.  Lied  to by agencies so I lost disability.  concussion  Dermatology  Food  Gynecology services.  Would prefer a female DR/ARNP  Have to travel 100 miles with a bad back.  I am sole caregiver for my husband and need help with  blood pressure and pulse monitoring  Insurance ran out.  lung/alphal  Lyme Disease  Maternity Care  Mental health drugs, emergency health care for kidneys. I  know of 2 people who needed help and couldn't get what  was needed and both died. 

Diabetes  0.3%  Dental  0.3%  Other 

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APPENDIX I

No local MD's  Not enough rehabs accessible to those with little to no  money.  pain clinic, physical therapy, with no insurance  PCP ‐ Nurse Practitioners  Pediatrics  Pediatric occupational therapy  Physical therapy  Specialty doctors  substance abuse programs  Too far to travel  transportation  urologist  UTI problems 

  "Other" services with access difficulty (open‐ended responses to question 4b)      Transportation  Transportation  transportation to get to these locations (no public  0.8% 
transportation or taxis)  transportation to receive health care  in town service for people without a car  Help with disability, cleaning, driving, etc.    Disability needs to be recognized, most people that have it  don't need it and to get it you have to jump through hoops if  I could jump.  financially limited. went for help in plymouth 3x $15 gas or  hannaford card and has told they cant help me forever. if i  need help its hard enough to go because you feel embarassed Food stamps  Help with SSI, finances without feeling that you're an idiot.    Affordable childcare  As a nurse I see mainly non‐insured have difficulty.  Autism  cancer support groups  Community people to help low income.  Businesses need to  kick in $ to hand out without red tap.  Housing, low income  people are real people, have no chance to own a home.   Support services used only for severly injured.  Depressed  and chronic back problems, people needed to help.  deprivation of character moral support  Durable medical equipment  Free things for low income help ‐ housing, food, clothing.  Getting MD's for all medical when you have state insurance. 

Financial/Eligibility  Assistance  0.7% 

Other 

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APPENDIX I

healthcare by a physician that wasn't in a "fast food" type of  practice like Midstate  Healthcare we can afford.  Housing  insurance  Limited income ‐ no insurance  List of services for the elderly and low income  New patient for doctor ‐ medicare only insurance.  No way to get home if no support system.  Out of area/insurance denial.  Physical therapy & massage  Vision care + Glasses for adults  Without dental insurance. 

  "Other" reasons for difficulty accessing services (open‐ended responses to  question 4c)     Coverage/eligibility  Legally blind, stated I did not qualify for service  No dental insurance or medical coverage for massage  limitations  My Health Care insurance company did not have any local  0.8% 

providers.  Insurance limits  Insurance would not cover my diagnosis.    No dental insurance  No dental insurance or medical coverage for massage  No dental insurance  0.7%  Had no dental insurance  No dental health insurance      Distance was a problem.  Travel/distance  distance to services  0.5%  too far to travel    Autism  Other  No money to pay.  Medicare only insurance, would not accept new patients.  Not local (good ones)  Too much money  People explain but they don't care and people lose law cases.  Lost disability because I worked for State of Mass. doing  specialized foster care, had to sign waiver that I would not  work outside home.  For 6 years income not counted.  Needed case management and supportive services.  Most in am, can't go in pm due to health reasons.  didn't diagnose problem correctly 

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APPENDIX I

i called for a visiting nurse but recieved no answer  Littleton, NH Social Security office NEVER answer the phone.  Insurance  unable to find another provider interested in a healthy  person  insufficient substitute for darvace T curing pains  we had run around with our 19 year old‐ trying to get mental  help for her! we had the run around, everyone would point  to another person ‐ now she is 23, still mentally ill, homeless  and there is no place for her to get long term help, she is in  and out of place with strangers, she has been assigned a  guardian  Sorry, have to say all of the above.  They do not count all of my bills for food stamps ‐ not fair.  No insurance  became homeless and was told I did not qualify for financial  assistance. lost my home & family due to a stalking issue  Because the services are more money than we can afford.  Was denied health insurance coverage by current insurance  provider, but make too much money to qualify for need  based programs, spend the first 12 weeks fighting with  insurance companies in order to recieve coverage.  Was more  of a health insurance/state regulation problem rather than  community coverage problem  limited number of mental health counselors within a  reasonable distance  I have 2 children which makes me a relative caregiver. One of  these children has special needs & during the summer it is  difficult to keep her occupied  Child was misdiagnosed with ADHD for 3 years from  pediatrician. 

  Medical Services respondents would use if more available (open‐ended  responses on Question 5)  Dental  Dental  Doctor, dentist, pain management, physical therapy for a bad back  Services  Health & dental care.  0.7%  Affordable  Health Care  0.5% 
medical/dental primary adult doctor    Affordable, low cost, hassle‐free health care.  There is a "low  cost/free" clinic in the area.  Once a week for 2 hrs.  Often, it is too  crowded and people can’t be fit in.  for uninsured  Nobody should be denied because of financing.    primary 

Primary 

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Care  0.5%  Specialists,  in general  0.5%  Cardiologist  0.3%  Mental  Health  Services  0.3%  Other 

APPENDIX I

medical/dental primary adult doctor  basic pcp checkups without insurance and physical therapy routine  appointments for chronic health issues    Specialists  Specialty needs to be closer  specialists    Cardiologist, local durable medical equipment and in home services.  Regular heart specialist    Mental health, general peer support especially if stressed out.  Therapy/counseling    affordable hearing aide, eye glasses  clinic in town  Dermatology, Endocrinology  doctor expert in orthopedics of the spine  ER, doctors office  Insurance didn't cover.  insurance doesn't cover  Insurance doesn't pay and not affordable to go to people.  Only goes  so far.  A lot of MD's past area that transportation will go.  Insurance doesn't pay.  MD's that know about disability laws.  Need affordable Health Insurance Plans available to all ‐ no matter  what your income or previous history  Need MD's that aren't covered by state.  Payment plan for dentures.  Rehab facilities, in‐patient & out‐patient.  rides for those unable to drive to dr. appt/ treatments 

  "Other" services respondents would use if more available (open‐ended  responses to question 5)      Dental care  Dental Care  Affordable adult dental care  0.5%  Affordable  programs/services  0.5%  Transportation 
train/rail service    $ wise, area is mostly under income, need good free  programs.  That treat us like first class citizens.  All have to be available, affordable for low income.  Reasonably priced trips for fun.    Rides to all transportation. 

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0.3%  Other 

APPENDIX I

Huge deal for younger demographic who cannot drive due to  visual impairment.    Advocates that are well informed and will follow through.  Budgeting/Financial planning  cancer support group and counseling  Community council  Depression  disability needs to help people not deny because of $ issues  Family Activities  help financially, food, clothes  Horseback riding therapy  I go to what's available for parenting support groups.  indoor pool for exercise, informational lecture/meeting on a  variety of issues such as wine, women, and wisdom  Judges on disability need to look at the paperwork and read  it, not just assume.  NANA is great.  People to come in to house free to clean or do things I can't  do because of disability.  Public education on Sensory Processing Disorder  We have no need for these programs, there are only 2 adults  here.  Would have used many of these in the past. 

 

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APPENDIX I

Question 6: What do you think is the best thing about living in your community? FAMILY, FRIENDS & NEIGHBORS; Helpful People, Sense of Community Support (25% of  respondents)   Friends and family.  People helping people.  Small country living - pleasant neighbors.  Good neighbors, EMS service and living in the country.  Friends  Friends, location.  The people.  Kindness, friendliness, congeniality of the people.  Most people will help each other.  Knowing many people in the area.  Strong feeling of community.  The people with an open heart and good soul.  The people.  People - setting - school (Plymouth/Ashland)  Friendly people.  It's support based.  There are kids around for my daughter to play with.  The support from people.  Everyone tries to get you the help is you need it.  Close community, everyone knows everyone.  People are friendly.  Everyone knows everyone else.  Family closeness.  Support system for school age daughter.  It's a small town with good people.  Involved caring people.  The community.  The people among the community are very caring and kind, and they do offer a decent program for aid.  The people who live here.  The people are so friendly.  Pleasant, neighborly  That most everyone is connected on one or more ways to everyone else, a small community such as ours is interconnected in a way that larger areas are not.  It's a small community, so it’s comfortable and easy to get to know everyone.  Pleasant atmosphere. Kind people.

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APPENDIX I

People are friendly and most try to help or understand what needs to be done. People help each other out. Friendly Strong community It's smallness - it's a close-knit community. Safe, friendly place to live. Our caring community who are devoted to making this the best place to live. The community awareness of its need to help others. Community is involved, many services available. Small and know everyone and are willing to help each other. Being a small town - knowing everyone. I like the neighborhood and my handsome neighbor. This is a caring community. People are friendly and try to help one another. It is small, lots of family and friends around. A sense of community with people willing to step forward to help others. The people People know you Close knit Community support, friendliness of outgoing neighbors. The closeness of the community, everyone knows one another. Small, everyone knows each other and helps. Everyone seems to know everyone and most of the people in this town will help as needed The friendliness of most people. Friends Friendly people People are friendly. The people, very friendly. The people are very nice and helpful. Small, caring community. Small community - generally people pull together to confront issues. It is a friendly community. The amount of people trying to better the community. Businesses are closely knitted together and are willing to help each other out. People work together. You do not get lost in the crowd. A sense of belonging Intact neighborhoods away from off-campus areas thrive, and people are still "neighborly. People Volunteers close knit, friendly The size of the community - when someone is in need people generally come together to help. Nice area and good community. Friendly atmosphere. people and friends are nice It is a community that cares 24 of 62

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APPENDIX I

The ability I have to support others Easy and possible to connect with others Community friendliness. Generally supportive environment Family Knowing other people Friendly atmosphere where everybody knows each other. Living in an area with like-minded people; those who care about an active, outdoor, environmentally sound and community oriented lifestyle People Clean water, clean air and community support & interaction with people willing to be supportive and helpful. Everyone is close together and are familiar with each other. pro-active people making a difference by volunteering My community is beautiful and they seem to care what is going on with people Small town community, knowing your neighbors people care about 1 another and respond when needed small close knit community everyone knows everyone friendly people, being a close knit community. great doctors knowing you can count on your neighbors close knit and caring the people- safe and clean it’s my home community spirit the friendliness of people and their support quality of life relative to safety, recreation, community values, clean air, natural beauty and safety services, education the support i'm getting I have a better support system here. quieter communities closeness of the community people care about others more than in big cities friends, church, cultural events, rural atmosphere people work together sometimes That it is a small community; people seem to care more for their fellow neighbor. The small size. Everyone knows everyone else. The best thing is how it is "city like" but we still have hiking and plenty of health programs. Everything is close knit, but we are all individuals. I love the location and the people in Plymouth. Ashland & Plymouth work together. It's small (Bristol) so I know a few people were like at the school etc. and it makes me feel comfy, etc. Friends & family that help support people with disabilities.

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APPENDIX I

The sense of community. Mostly it is safe, clean and beautiful with a caring community. Knowing people Close knit - people who care Sharing small community w/people, getting to know small town and neighbors Being part of a community, rural environment Sense of community in rural area People, most of them are nice and helpful people care about each other; the outdoors Small community- people know each other and do their best to help everyone else out More of a tight knit community... families and friends overlap in many different parts of the community to work together. The feeling of community small enough to know most people but getting large enough to support the growing community. The people...when someone is in need the community comes to their aid. I love living in a rural community because we know our neighbors and provide assistance to each other in times of need. The close knit neighbors that support you in whatever your needs are. I enjoy living in a community where people know each other and support each other. Members of the community support one another in times of need. Community is small enough so that you get to know people. Sense of community The community connections and the after school program opportunities in the Newfound area, beauty, sense of community The people and the landscape. people willing to help others in need small-town knowledge and support of friends the people are so friendly here some people are helpful. engaged community Sense of commitment to change & supporting others. people truly care about one another It’s a quiet and caring community The quality of the people. Everyone is so willing to help out when there is a need. small community...people help others Support each other when support is needed. In a small town, people tend to take care of others, even as just a neighbor. We have clean air, less traffic and noise pollution, and beautiful scenery too. The faith based community is strong. People don't hesitate to come together to address common problems. There are caring people who try to make a difference People I think the people are the best thing in the area. The area is filled with truly wonderful people. 26 of 62

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APPENDIX I

Small community size, neighbors who look out for each other. Everyone knows each other.

SMALL COMMUNITY, RURAL; Quiet (17% of respondents)   It's still small enough to be good for raising a family.  It's a small town where everyone knows each other, friendly.  Rural living.  Quiet and not congested  Everything is close by.  The quiet rural area that I live in.  Very quiet.  Small sized community.  It's quiet.  Not too many people.  It's not a bad little community, the people are ok.  Alexandria is a quiet community and we love that there isn't a lot of people around us.  That it is a small community.  Small town  Quiet neighborhood, decent people, small town.  It is not the city.  Ease of getting around.  Rural - small town  Size  Small!!  I like living in a small quiet town.  Very rural  I like the small town atmosphere.  Being on my porch.  Small communities networked with surrounding communities, outdoor opportunities.  Familiarity  Rural, minimal government involvement.  Rural living.  Peacefulness  Rural character  Getting to know the other residents due to small population. Natural beauty of the area.  The stress free living.  The scenery and the small town feeling.  Living in country w/lakes and mountain. Small country town.  Small town environment.  Small and friendly.  Small town  It's quiet, people are very nice.

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APPENDIX I

Not too much traffic and commotion and green mountains, clean hikers. It's peaceful when college is gone. The peace and quiet It's rural. Rural setting, small town community, family-friendly "small town living" Small town feeling small town, college, beautiful setting Friendly. Removed from pressures of city life; e.g., kids wandering the malls at all hours; also , access to good outdoor activities IF people would access them more Small town atmosphere Beautiful natural area. Slower pace of life. Rural character IT IS RURAL Being in a small town community with mountains and rivers Small town community. Fresh air, small community. Small it's quiet small towns, friendly people, the environment small, convenient town quiet rural, serenity, friends a non-city environment no crowds, little pollution quiet, for the most part safe. would not let my child go out at night though. small town, beautiful, grew up here, resources - even if they don’t apply to me the people are very friendly, love the NH lifestyle, the beauty of our surroundings (mts, trees, wildlife) rural nature small town nice quiet place, easy to relax peace and quiet - respect of a nobler person's privacy a nice, small, safe friendly country - we don’t have malls or busy, busy traffic. laid back, everyone knows everyone small town mentality - bring pets to work; more relaxation at work and home Being in a rural area, less traffic It is smaller & people are friendly. Not congested - not too much fear of crime. The feeling of living in a small community where you know a lot of people, you see each day and the comfort of feeling safe in your neighborhood. That it's not too busy and most people are friendly.

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APPENDIX I

It's quiet yet close enough to towns that have more going on. It's small and quiet. Fairly quiet Quite place Small town The quality of life because of the small town atmosphere. Rural Quiet compared to the city. Healthy environment - able to walk places, downtown has viable stores, services. Access to outdoors. The rural nature of the setting - the availability of access to trails, streams, lakes & mountains Outdoor activities, lakes & mountains. Small friendly community. Small community Small size of community Small and quaint. Friendly The beautiful area and the kind people. The small size quiet and friendly small town feel location It's is rural, so there is a nice atmosphere, it isn't overly crowded, people are friendly. I live in an area where I can breathe fresh air and get fresh water from several springs. I like small town rural community. little traffic, fresh air, quality of life quality of life Low volume traffic It is very quiet and peaceful small town feel

PHYSICAL ENVIRONMENT, NATURE, OUTDOOR ACTIVITIES (16% of respondents)   Clean air.  Less populated, clean environment, easy to get around (if you have a car!)  It is a truly beautiful environment.  Access to outdoor activities that are free or low cost.  The location.  Beautiful views, beaches, hiking trails, small community feeling.  Surroundings  Location - beautiful.  Rural small town, lot of parks and trees and hiking.  Not sure, the view.  The area of our home and the town of Bristol right by the lake for my kids in the summer.

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APPENDIX I

Beauty of the area. The mountain, lakes and hiking trails. Environment - nature. Access to the outdoors, parks and hiking. Clean air and water. Low crime. Beauty of area. The mountain air! The Longue view. Beauty of NH View! NH mts. Fresh air, no traffic. Newfound Lake Newfound Lake especially state park for seniors. Natural environment, friendly people. Quiet, natural, beautiful. Clean air and water, open space, recreation opportunities, safe. Clean environment Environment The people and the mountains. Access to nature. Living in a rural environment. Access to nature and bike/walk path It's beautiful and a healthy environment & community. Lots to do and see. Environment It really is a beautiful area with Newfound Lake People, beauty of the mountains, lakes and rivers. Clean air Access to the outdoors & recreation. relatively small community, access to outdoor activities. Lake Newfound Environment Natural Environments~ lakes, rivers, trees, etc Community relationships The nature Location in terms of outdoor recreational activities Beautiful lake/mountain community which avails you to enjoy many wonderful outdoor activities. It's a healthy environment. Wide open spaces. Fresh air - no big cities. Wilderness Outside It's a beautiful area. the beautiful land and nice people opportunities for outdoor activities the great outdoors fresh mountain air Fresh air, fresh water. 30 of 62

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APPENDIX I

The beauty of the mountains. Friendly environment, outdoor activity opportunities. The people and the beautiful landscape! Scenery The beautiful nature. The natural resources and outdoor activities readily available. Clean air, fresh water, good people. Clean air/water Easy access to beaches & mountains. The rural nature of the community. Provides a landscape of natural beauty where one can find peace & quiet and solitude if one so chooses. Close to nature How beautiful it is. The beautiful environment Lakes and mountains environment - clean and safe Rural environment provides for easy access to fun, healthy, FREE, outdoor activities. Living so close to the Mountains, lakes; lower crime rate; small population-no traffic; outdoor recreation accessible. The fresh air The natural environment lots of things to do outside Rural, and clean air open space nature Nice scenery, environment and outdoor recreation opportunities the scenery nature Outdoor resources Outdoor activities...hiking, biking, walking, kayaking, tubing Living in an a rural area which has so many natural resources fresh air and the mountain location The natural beauty, lakes, mountains. Country. Mountains and water. Friendly people. nature is close and an important concern to others it's rural with a lot of outdoor activities available. The beautiful surroundings Nature and peacefulness rail trails, access to trails and nature Our God given beautiful environment. Not congested, open, mountains & lakes, outdoors Nature....lakes mountains hiking swimming fishing etc The people can be pretty great too

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    The activities available to do outside. Fresh air, clean environment The availability of amazing outdoor recreational opportunities. Living in nature

APPENDIX I

ACCESS/PROXIMITY TO SERVICES, PROGRAMS; Cultural Activities (9% of respondents)   Access to services  Stores are close by.  I enjoy being close to a police and fire station. There is also great places to take walks.  Everything is close by.  Education and cultural opportunities available thru PSU and other groups  Services and property tax benefits for the elderly and veterans.  College programs - educational and recreational. Very good medical facilities & personnel. Changing seasons. Excellent senior citizens center.  It's pretty quiet, they do have food pantry and discount clothing.  We have a senior center.  Senior center  Everything available, senior center, vans, meals on wheels, churches  Easy access to health care, shopping, senior center, college.  The senior center.  Most everything is close by to where we live.  Services available.  Renewable energy conscious people. Farmers market, community garden, local foods, Plymouth, PARE1, Silver Hall events, etc.  Proximity to PSU and all it offers.  Most things close by  Community Center programs - the generous people - NANA - Community Service  Cultural events - even though can't get there most of the time.  Senior housing.  Tapply Thompson Community Center  The friendly atmosphere. A place for young people to go after school (TTCC) and after school program.  Great diversity and access to Plymouth State and Silver Arts.  They have the Plymouth Regional Clinic but needs more days open.  There are many options for low income homes. There are a lot of child activities local.  The cultural center which PSU provides  It’s walkable and we do have many youth programs and services for the elderly.  Access to medical facilities  Small-town atmosphere but still close to services  Resources and referrals available to those who ask. people are willing to help in most cases.  The variety of opportunities available in services and events are well supported by the community as a whole.  All the services for youth.

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APPENDIX I

We are lucky to live in a college community, it brings cultural events and diversity. Services/support of a small community. We do have a health care clinic. easy access to everything youth center clean, safe, cultural opportunities available, plenty of outdoor activities, Speare hospital, doctors offering reduced fee health care to people in need. strong sense of community we know almost everyone, services are accessible there seems to be a lot of communication between service providers childcare system It's close to Plymouth. It's small, getting to know people - having Pemi Youth Center, the clinic and meals for many. Small town atmosphere, cultural pursuits. Everything close to town. The resource centers. Whole village, circle program and Genesis. There's so much available to help the community and each person who asks in the community. Support groups. Doctors and mental health. The willingness of support services to want to help and be supportive. Access to Plymouth library, parks and recreation, hospital. The people and the cultural opportunities are very important. The beauty of the state tops the list at all seasons. The small size and accessibility to most services. good people; community arts, recreation and sports, PSU-related activities and facilities The physical space we can opt to have in a rural community combined with the closeness of a variety of social activities. Whole Village

SAFETY, LOW CRIME (7% of respondents)   Less crime.  A nice small town with a low crime rate.  I don't worry that bad things are going to happen, as much as I would if I lived in a city.  Generally low crime.  Safe neighborhood  Safety, Bristol is a safe place to live.  Crime rate is better than surrounding areas.  It's quiet, crime "free" practically, friendly.  Country setting. Not a lot of crime or violence.  Not as violent and congested as cities.  I feel safe there. There is available help if needed.  It's quiet. Don't have to worry about violence or crimes like you do in cities.  The community is very kid friendly and safe.  Less crime than larger areas.  Safe

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APPENDIX I

Low crime rate. Low crime (3 comments) small community- crime isn't as prevalent as in urban areas low crime, healthy environment Crime very low Area beauty Neighborly people Lack of violent crime. that it is a friendly community with little crime safety and friendliness safety clean, low crime good people relatively safe and congestion free it feels safe & friendly; it has a real clean environment Small, not too much crime. Safety Small town, safe. It's small, quiet and relatively violence free. Feel safe in my home. Crime is really low. The crime rate is low, people watch out for each other and the air is healthy The police are fairly on the ball, There are a lot of agencies that do referrals and it seems like a safe place to raise children. it is small and safe not only is it beautiful but its reasonably safe Safety, good place to raise children It's Overall A Safe Place To Live

GOOD SCHOOLS; Educational Opportunities (2% of respondents)   Good schools.  I like my kids school.  The tremendous schools.  Some nice schools like New Hampton School and New Hampton Montessori for little kids.  There is great support in the schools and lots of opportunity to get involved in the community service projects.  Educational opportunities  Fresh air, less crime, good school programs.  Great schools.  Wentworth Elementary school is FANTASTIC! I have four adopted children with special needs. Three of which have been in the school at one time. The school goes above and beyond what is asked of them and is always looking in my child's best interest.  school  beautiful undeveloped spaces, great schools, Thornton Elementary and Plymouth Regional High School  Safety, schools

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APPENDIX I

OTHER   I don't live forever.  Very nice area.  Nothing!  NH is a great state.  It's ok.  In most part - health - minded people.  The good outweighs the bad.  There seems to be a lot of resources, but they are not promoted well outside of local agencies there should be a paper listing all community events in the area and community resources that are free.  Very few MA. People  It's beautiful and peaceful here. gay marriage is legal!•  minimal invasion of privacy by "do good" services that everyone demands and no one can pay for  The people are all in the same "fix" with the "economy" try to live as best we can and be happy  live in a beautiful place, but it’s what you can’t see that need to be addressed  no one really cares or is informed in legal issues, medical issues  No 24 hour police in Lincoln.  Great state, nice people  Community services when not taken away.  The cities.  Community needs to pull together and help. If they have information give.  Don't know  Lived here all my life.  Live free or die  After living here for 35 years- I'm asking myself the same question.  The best about where I live is distance from all the outside influence I don’t agree with

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APPENDIX I

Question 7. What do you think is the most difficult thing about living in your community? LACK OF TRANSPORTATION/PUBLIC TRANSPORTATION (18% of survey respondents)   Being far away with no transportation.  Not having any public transportation.  Difficult public transportation.  Transportation (15 Comments)  Geography - need public transportation.  Getting around, there is no bus after Wednesday.  getting from place to place if you don’t drive  Getting to and from services.  Hard to get around without a vehicle  Inability for individuals to access services due to the lack of transportation.  Lack of integrated public transportation.  Lack of local transportation (10 Comments)  lack of public transportation and lack of employment for some  Lack of public transportation and vision for the long term benifits to our community and the earth.  Lack of public transportation is a huge challenge, especially for those who cannot afford an automobile. This area really needs more public transportation than just the seniors bus and the college shuttle.  lack of transportation  Lack of transportation for the public.  Lack of transportation for those who need it.  lack of transportation, public and affordable!!!  Local public transportation  Local transportation.  No public transportation (9 comments)  no public transportation everything is spread out  No public transportation to anything  No public transportation to get to appointments or resources  no public transportation, few sidewalks, safe road side biking walking areas  No public transportation must have a vehicle for everything.  No public transportation. Cost of living.  No public transportation. Services & store too far away.  No public transportation. Not a lot of non-judgmental support available.  no transportation if you dont have a car  no transportation (4 comments)  no transportation for seniors on those who do not drive  No transportation without good car  no transportation, low budget

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APPENDIX I

No transportation. It's a struggle to rise above "below poverty guidelines". public transportation is not available Public transportation (7 Comments) Public transportation - access to needed services. Public transportation for seniors. Public transportation or volunteer transportation public transportation! Public transportation, access to health care. Public transportation, especially as gas prices escalate. Minimal public transportation. Marginal employment opportunities. Heating costs - long cold season. Road safety (or lack there of) for walkers and cyclists. Not enough public transportation in the area. Not enough public transportation. With the rise in the price of gas, available public transportation. Transportation challenges. Transportation - availability and cost. Transportation - especially for transitional teens - after high school but before...? Lack of options for them regarding transportation, training, jobs Transportation and jobs. Transportation by handicapped equipped vehicles. The taxi is expensive and not easy to get into. Transportation for carless people. transportation for those who do not own a vehicle Transportation for those with disabilities. Transportation for those without their own car is expensive or impossible. ie: Health care for bariatric surgery is available in Concord limiting it's availability for many local residents who need it. Transportation needs. Transportation to access serving in community. transportation to different places Transportation to Plymouth from outlying communities. Transportation! transportation, opportunities Transportation. Limited services tough to get around, not a lot of public transportation There is very little opportunity to travel if you don't drive. no public transportation for anyone who is not elderly expensive gas, lack of public transportation

TRAVEL DISTANCES TO SERVICES/COST OF TRAVEL (13% of survey respondents)   20 Miles in different directions for major shopping.  a lot of specialty services are available far away only  Access to many services, long distance to movies, specialty shops.  Being close to services

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APPENDIX I

being far away from medical specialists - typically have to go to Dartmouth Hitchcock Medical Center in Lebanon or somewhere in Concord or Manchester Being so far away from this, not enough options. Getting around, gas, etc. Children have to be transported distances. The cost of living makes it harder for people on fixed income - need to travel lots to get to where you need to shop. Commuting and transportation are very difficult and costly. cost of traveling to get anywhere Difficulty for students to participate fully in after school activities because of the need for transportation everywhere. Also, too many adults driving too many cars due to the rural nature of living. Distance distance around Newfound lake Distance between town for food, clothing and medical care. Distance from everywhere else! Distance from medical specialists - particularly those treating life threatening illnesses. Distance from services, errands, and appts. Distance from services, stores, etc. Distance from some services. distance from specialty health and family care services distance to a store distance to emergency medical care Distance to more diverse shopping and extended health services. Distance to services distance to services and shopping Distance to services. Distance to shop, work, school, church. Distances between the 7 towns. driving everywhere, distance driving everywhere expenses, long distance for goods and services Far away from everything. Few nearby resources- long trip for fresh groceries or specialty healthcare Gas for traveling Gas prices. Getting around. (3 Comments) getting from one place to another, here to there Having to drive 30 minutes to find activities. Having to drive everywhere! Having to drive long distances to get some services. Having to drive quite aways for better opportunities having to drive. No good access to the airport. Public transportation east to west.

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APPENDIX I

Having to rely on personal transport with little public transport. Having to travel for health/mental health care, fewer resources available. Having to travel to Tilton where things are less expensive. Having to travel. Housing & transportation If I didn't have my own transportation that would be most difficult to get around. It is really far from drug and alcohol treatment centers. It is remote - no nearby services - travel to services is required Lack of variety for shopping. Distance to health facilities. large geographic spread. Lack of access to transportation and close services for many Limited resources in small town (esp. transportation). Have to have a car to get to work, appointments, etc. Limited transportation, limited job opportunities. location Location - travel to go anyway. Higher gas prices with tourist area. long travel times Must have a car to get around. Need a vehicle to get anywhere. So far from so many things. So rural/transportation. nothing is close- have to drive to everything. if u dont have a car- it is difficult to get anywhere Shopping in Plymouth area = 10 mile trip each way; gas prices are climbing. travel distances The amount of time it takes to get to stores, doctors, etc. The rural nature of the community. You have to travel to find services or to go shopping etc. Travel (2 Comments) Travel distance to get to services. Taxes Travel to first class health facilities travel, winter Traveling for good extra curricular activities for my kids (dance, karate, etc.) Traveling so far for decent shopping, no competition with Hannaford & Walmart Traveling to city for education programs and medical care. Traveling to most facilities requires an automobile; great distance, no public transportation options (Rail or bus). Town is 15 minutes away from home.

JOBS/EMPLOYMENT OPPORTUNITIES (8% of survey respondents)   "no jobs" and more lay-offs...no money  a variety of interesting, stimulating, good paying, good benefits jobs for young people especially  Access to jobs especially those with health care benefits.  no job opportunities  Employment opportunities

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                                     

APPENDIX I

Finding a good job with enough pay to afford the cost of living. finding a job that pays enough to live comfortably Finding a real secure job and housing. Finding jobs and public transportation. Hard to break thru with a new business. High unemployment or underemployment I would like to open a business here, near home but the community doesn't support local businesses enough. Need jobs & opportunities. Job opportunities Job opportunities, there are none. Job seeking Jobs Jobs and quality, affordable Jobs, there are limited job opportunities in Bristol Jobs. there are none. Lack of job opportunities (2 Comments) Lack of jobs and industry. Lack of jobs Lack of jobs. It needs more jobs. Lack of jobs, public transpo, Lack of employment - no public transportation. No insurance Lack of employment opportunities lack of employment opportunities and lack of transportation, limited financial help at speare hospital Lack of employment opportunities. Lack of QUALITY paying jobs AND employers! HIGH property taxes --being 'bled out' ! EASE of getting state assistance for a variety of programs which causes ABUSE/FRAUD of this availability Less job opportunity. Limited jobs. No jobs (2 Comments) Not a lot of job opportunities and transportation issues. Not a lot of job opportunities. not enough job opportunities Not enough jobs Not enough salons hiring. Opportunity Sustainable job opportunities There is not a lot of job opportunity. The unemployment rate. There are not a lot of job opportunities and it is two hours away from a major metropolitan area.

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APPENDIX I

ACCESS/AVAILABILITY  OF  LOCAL  SERVICES  (mental  health  and  dental  broken  out  separately  below)  (7% of survey respondents)   Access to free health clinics.  Access to health care.  Access to legal aid lawyers or pro bono is near to impossible for those who really need it.  Access to medical services for the uninsured.  Access to programs.  no access to doctor for myself or dental  Getting the services I need.  difficulty in getting services for family in rural areas  Fewer resources and less access to services.  Fewer resources available 2/+ small population.  I love that it is a small town but this is a problem as well in terms of variety of available services, and privacy.  Inadequate access to semi-emergency health care.  knowledge of and access to services  Healthcare  Lack of access to services, transportation  Lack of parenting support.  lack of resources or fragmentation of resource information.  access them due to lack of transportation and parental involvement.  Lack of resources.  Lack of retail options  lack of various types of support for people in need and lower class people  limited choices of food, shopping, physicians  Limited choices regarding employment and health care choices.  No, grocery stores in the downtown area.  Access to affordable local foods.  No medical help, help for inside homes includes neat etc.  Not all services available.  Not being closer to services  Not enough services (2 Comments)  Not having services for my daughter with autism.  Not much for children with needs.  Proximity to more specialized care, dermatologist or orthopedic specifically. there are several orthopedic doctors but wasn't impressed with their services. ended up over in hanover.  small towns don't always have the services available that the citizens need without having to travel very far to get them  So far away, no one want to come to the older people to help.  Sometimes it is difficult to get some services. Tri-Cap is now in Ashland and mental health in Laconia.  We don't have many services were I live--we are 20-30 minutes from a grocery store, movie theater, restaurants, etc.

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      

APPENDIX I

Try to get health care from doctors who will not treat new patients who only have medicare insurance. There are not a lot of resources readily available as there are in the more heavily populated areas. There are not enough resources to help everyone who wants to have help There's not enough help and info about what services are available. There isn't enough services for everybody that needs help so people that really need it go without and my neighbor is so naughty. No peer support. Lack of stores being open later

ACCESS TO MENTAL HEALTH SERVICES (1% of survey respondents)   accessibility to mental health services  The mental health field for teenagers is very difficult, especially when it comes to drug and alcohol situations. The counselors are busy and not taking new patients. It is also difficult finding someone who is in the local that is not part of Genesis.  Lack of resources to support someone that requires mental health services, but that cannot  access to mental health services for low income residents and those without health insurance.  not a lot of places for people with mental or psychological issues.  mental illness  people in a small community have blinders on concerning mental/emotional dxs. A lot of biases.  lack of psychiatrists ACCESS TO DENTAL CARE (1% of survey respondents)   No dental care  Access to dental services for the uninsured.  Accessing dental services without money or insurance.  Dental care.  HORRIBLE for dental care for adults with no insurance and no income (I have yet to find someone with 5 broken teeth).  Lack of dental care  no dental insurances for poor poverty class. LACK OF PHYSICAL, CULTURAL, SOCIAL ACTIVITIES; and related environmental supports (7%  of survey respondents)   Lack of activities for our children or more that are affordable.  lack of arts & cultural events  Lack of cultural opportunities & public transportation. Oh yeah, JOBS!  Lack of exercise/relaxation facilities for non-PSU people  Lack of family orientated affordable fun things to do and lack of public transportation  It is not pedestrian/bicycle friendly.  lack of paths for walking, running, biking, etc no community center  Lack of services LOCAL! No after school activities/clubs.  Lack of services.

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APPENDIX I

lack of side walk or bike lanes, along route 3 north of town center Limited quality family activities. Limited social and cultural opportunities not a lot of activities (adult sports and child playgrounds) Not a lot of activities to do. Not a lot of cultural opportunities no access to afterschool and summer programs for children. Not as many resources, cultural events, sometimes feels like too small of a population-no anonymity Not as many things available to me as what I was used to prior. Like a workout or gym facility. Not enough activities nor places to go to do things and not enough places for support, for those who have disabilitities. Not enough activities, like movies, entertainment during late afternoon and nights. Area is almost dead, with no place to go. Not enough activity. Not enough age appropriate play groups for children and parents. Need to let parents know when/where to go for them in many towns surrounding Plymouth. Not enough community group activities. Play group needs to be run by one person/organization, not a group member. Better community center. Not enough free programs for children 10-teenagers. No specialty MD's in area. Food pantry foes not give enough and fresh & frozen food (a lot) are no good Not enough social activities for young adults besides bars - drinking activities. Not enough employment opportunities for semi-professionals. Not enough to support a Y or such. Not enough walking/biking access/paths. Dependent on auto, no public transportation from town to town for anyone but seniors. Not much available for entertainment. Not much for children. Nothing to do Sidewalks and roads in poor repair, makes walking, biking difficult. could be more community events Younger, peoples "hang out" not enough for young people to do; they tend to move away The lack of access to more social activities and late night hours of restaurants and store open. The lack of things to do because of the small town atmosphere The rural qualities and lack of opportunities for kids to keep busy, especially on the weekends, evenings. Lack of social activities for older youth and young adults. There's nothing for children there's no place to go to enjoy for free for seniors--like--exercise room and pool--basketball court--tennis court There is no gyms that are affordable for single mothers with nutritional ideas, lack of availability of exercise pools etc open to public, gyms 43 of 62

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 lack of children's recreation

APPENDIX I

FINANCIAL BURDENS; taxes (6% of survey respondents)   Financial Burden Of Taxes  financially there is no help, no good programs from school for kids after school  I'm struggling financially, wish there was more people that could help.  Lack of money.  Amount of under privileged people  Due to the seasonal nature of much of our employment base, way too many people live too close to the edge.  It's a poor community and many people take for granted they will get help. We forget how to help ourselves.  no break on property taxes for seniors.  not enough local help for those who are just over the guidelines of welfare and food stamps  Not enough MD's or programs for poor. thrift stores, getting real $.  not making enough money to live  People are house "poor". Property taxes are high and people tend to not vote for any services that will increase their property taxes. Towns need other sources of revenues, other taxes.  Prices for food and gasoline, trying to get help for something and they think you make too much money!!  Seeing so many kids living in poverty.  Taxes (4 Comments)  Taxes (property)  Taxes going up for middle class people.  The economy.  Town administration/administrators out of step w/economic hardships in this town. (Spending $ we do not have, making it too expensive to live here and it is NOT a hub).  The extreme poverty. In Rumney, half the children qualify for free/reduced meals. Alcoholism soars because people are stressed. Abuse increases. People can only afford to eat junk and God forbid if you get sick!!!!  When things are being taken away and making life harder for the lower income people.  The prices of everything.  very poor people that do not make good choices for themselves and families  watching people struggle to make ends meet, homeless people  Trying to get help to pay for utilities like the light bill.  Not enough financial (town) help they're very strict on what info they need and want to matter what.  low incomes, cost of living is high  There seems to be fewer jobs available for full time work, and incomes have not increased at a rate even close to the costs of groceries, heating oil, gas for transportation, taxes, and more. It seems like a high cost of living  gas prices high  economic support for families

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  Cost of energy Heat

APPENDIX I

ISOLATION OF RURAL SETTING; COMMUNITY CONNECTIONS; DIVERSITY (5% of survey  respondents)   Is rural and getting what you need or finding out what is available can be difficult.  isolation  Isolation and access to adequate services  Isolation and the lack of community for young families w/professional parents.  Isolation due to lack of public transportation.  isolation for single people  Isolation for those living in some of the more rural areas and poverty for many.  isolation, lack of services  it is isolating living in a rural setting with intermittent transportation  it is not close to more family supportive resources (i.e. lack of jobs, opportunity, for young families)  It's rural.  It's rural. It is already hard to be accepted into programs, or into doctors’ offices, and then on top of that most places aren't within walking distance, you need a car, or a ride, gas money, the ability to take a day off of work to travel.  High priced utilities, gasoline. Personal isolation in rural areas  Being gay  lack of diversity, specialty retail options for ethnically diverse individuals  No one cares about each other.  Not knowing other people  physically spread around too much  Remote location, inadequate access to services in distant towns, lack of racial/cultural diversity  rural isolation  Rural isolation is a problem for those who don't drive or work.  rural...  Sometimes because our small communities have such polar opposite views, it is difficult for town governments to get things accomplished. Also, our communities can feel isolated sometimes.  sometimes people are close minded, community is not as diverse as I might like  Would like people closer to the town.  The distance between all the surrounding communities. Rural area  when help is needed we live just far enough out it takes a while for help to get here  We are kind of remote or in a remote areas so a lot.  The lack of diversity. It begins with the lack of cultural diversity and trickles down to everything else including food choices, art, music, recreation etc. People can't learn tolerance if they don't experience differences in every aspect of their life. Bringing a 'Multicultural Market Day' to the Plymouth area would be amazing.  The size of the community - sometimes people just aren't accepting enough of differences.

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 establishing relationships with members of the community

APPENDIX I

WINTER (3% of survey respondents)   Cold winters!  Cold winters.  Getting through winter.  Winter (3 Comments)  Long Winters and isolation  Long winters. (2 Comments)  The weather in winter.  the weather is oppressive  Snow removal  the long winters, as a person with a disability it is hard to get out much, no public transportation  Isolation, long winters, heating costs  The cold weather and long winters.  Weather  The snow sometimes.  Too much snow. Transportation HOUSING (3% of survey respondents)   cost of housing  Finding housing with a garage.  High rent  Housing & transportation  Housing  decent affordable housing (too many slumlords)  Lack of affordable housing.  limited reasonable rents  price of housing  The lack of housing, transportation  Unaffordable houses, trailers or apartments. What's affordable gets taken. If you can't work or find work or keep work, low income housing is very difficult to get approved.  There are not many low income housing programs or programs to help low income people get dental care or eye exams or really any services.  poor housing  We need more Sec. 8 housing for singles/elderly  low income housing (2 Comments) ALCOHOL, TOBACCO & DRUG USE (2% of survey respondents)   All the drug use.  Board (?), drug use, alcohol use  Kids doing drugs and alcohol.  Drug use and alcoholics.

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       Alcohol & drugs. Lots of drug and alcohol problems -adults and kids Drugs (2 Comments) Nothing except seeing young teens smoking. Prevalent substance abuse Streets are full of drugs, getting help for disability. Too many drugs & people walking streets that police know about.

APPENDIX I

PROXIMITY TO THE COLLEGE/COLLEGE STUDENTS (2% of survey respondents)   College  College students not living/partying on campus  College town.  Dealing with drunk college students.  Disturbance issues with off-campus college students, excessive drinking and availability of alcohol.  inconsiderate college pukes  The road down town is not wide enough, college kids are always around.  Negative influence of college living in residential areas  The college kids being drunk at 3:00am cause mischief.  the college students, lack of local jobs  Traffic, too many college kids driving. Hard to get across streets, have to wait a long time.  The stratification of full-time residents in the off-campus neighborhoods poses continuing problems. Traditional residents are becoming more and more isolated in these areas, and increasingly frustrated by the unresolved quality of life issues. NOTHING (2% of survey respondents)   Can’t think of any  Nothing (7 Comments)  None  N/A CRIME (1% of survey respondents)   Crime (2 Comments)  Crime is one of the biggest problems that I see is underage drinking and prescription drug abuse.  Crime, theft  Some crime.  Youths in 20/30's causing disturbances/crimes. So many young children without any parents at home. Police harrassment of mothers with young children.  crime, bullying/cyber bullying in school LACK OF CHILD CARE (1% of survey respondents)   Finding child care for single working parent hours.  Daycare for children

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  quality, affordable, and adequate child care adequate child care

APPENDIX I

OTHER   Bad roads, crooked cops.  class distinctions  Discrimination - kids not getting enough help in school.  expert doctors  Factionalism between retirees on limited incomes and families with school aged children breeds antagonism. We must find a better way to knit these constituencies together.  How the elderly are not used for experience and or first asked to contribute. How they are just not included.  Finding help when needed.  For the reason above often confidentiality is an issue.  Garbage on the road and cigarettes thrown everywhere.  Lack of a good cable TV package. Too far away from shopping malls.  Getting help.  Getting things done that would make a difference.  Having/Finding people who will listen. Reversing the "rumors".  Lack of connection..2nd homeowners  Lack of the poor condition of streets and sidewalks. Repairs, especially to sidewalks needed.  Lack of understanding of what's available.  Law  Nepotism.  No 24 hour police in Lincoln - oops - I live outside your bubble.  No parking or little downtown.  not a lot of volunteer programs accessible,  Not everyone can get help!!  People (neighbors) know every time you need to ask for assistance.  small town community, knowing your neighbors  some breeches of confidentiality issues  People abusing the system - using ED as primary care.  People can be judgmental and uneducated.  people starting rumors  seeing traffic lights, big stores come in. it will attract city people and more garbage on lands, crimes will come. gas prices, elect, high, people coming in changing things and there are not from here. and its not to help our community or state. (seeing homeless people and animal abuse)  Segregated haves and not haves.  small town cliques and people who want to make our state like the state they moved from  support groups  the bears  When I have to go back to the city.

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APPENDIX I

The expansion and growth, like for example another pharmacy even though Plymouth already has 3 I believe or 4. The MA. people that are there. The young teens who hang around town at the local store, it's uncomfy to wait to go in when you have an anxiety disorder. Trying not to volunteer for everything that you see a need in doing to help out non-profits and community partners.

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APPENDIX I

Question 8. If you could change any one thing that you believe would contribute to better health in your community, what would you change? HEALTHIER EATING/ACTIVE LIVING (11% of survey respondents)   our health would be much better if we could have the right foods  Better food choices  Educate about better food choices, re: processed foods are bad, eat natural.  Education on eating right and exercising.  education on health living - exercise and food  Everyone needs to plant food and recycle.  healthier food choices and more exercise opportunities in the schools, especially middle and high school.  healthier foods at school and increased exercise (mandatory gym)  Healthier foods more affordable  healthy eating habits. More exercise programs, bettr eating habits.  Healthy food options school lunches, more exercise for the kids  Help people realize how important healthy/quality food choices are.  Learning about good food choices and exercise.  better food banks (no MSG, etc.)  make it so that only high quality, local & organic produce and food was available  Teaching children about good food choices  quality food - glad to see our famer's markets  Restaurant participation in healthy foods  More affordable fresh food.  Ability and Knowlege of providing healthy meals is MORE economical than the crap that is purchased for less money~ Offer Resource for budgeting and skills to shop and prepare meals!  A facility especially for seniors to go to exercise on machines and go to a pool for no or little cost.  Access to physical activity opportunities: bike paths, sidewalks, community exercise classes etc.  An accessible gym that does not have a waiting list, is affordable, and doesn't compete with existing student programs.  An activities center family with AFFORDABLE activities and exercise classes  Celebrate health and exercise.  Community exercise program  Community focus on healthy eating, exercise, and weight loss.  exercise programs - more walking and trails  Facilities for indoor exercise in the winter.  free or low cost exercise classes open to the community  low/no cost exercise opportunities  Have free weight loss/exercise classes available for all.

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APPENDIX I

try to get more people to understand what a huge effect exercise has on their health followed by nutrition. Town swimming pool great exercise and would also make summer recreation programs more exercise orientated as opposed to so many trips Require every resident to exercise. respect and courtesy of bikers (bicyclists), runners and walkers Opportunity for adults to participate in local activities like softball or other sports. Outdoor activities, exercise. Nutrition education and support groups. Obesity and healthier life style with exercise. more reasons to get out and exercise More free nutrition and exercise programs. Lower cost exercise locations for all ages. More exercise programs. Weight reduction. Safe, liveable, walkable community. a community fitness center, maybe a gym. add bike trails system; bring in a YMCA community center with many activities for all ages both indoors & outdoors Being able to use facilities (pool) at University Big gym (low cost) ie: Planet Fitness bike and walking routes everywhere people shop, Bike paths Bike trails (trying to avoid hills when possible). Use of old railroad tracks for biking, walking, etc. community programs for fitness and health eating habits Farmers markets would be good. sidewalks and walking areas to encourage fitness Sidewalks/shoulders so people can walk or bike more safely. Improve the school lunch program by providing healthier choices. Plymouth should have a public park, with a large year round maintained walking path, dog park section and children’s playground. people in general should walk more People should walk rather than drive. Walking has a direct effect on health. Bike lanes & walking. make community "fitness" a priority. Doctors encouraging exercise and healthy eating. Maybe speed limit for safer walking with children.

ACCESS TO HEALTH CARE/AFFORDABLE CARE/AFFORDABLE HEALTH INSURANCE (7% of  survey respondents)   Access to health care  Access to health care and affordable health insurance.

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                                     

APPENDIX I

Affordable health & hospital care. Affordable health and dental care. Affordable health and dental for all. Affordable health care Affordable health care, especially for the elderly who are on a fixed income Affordable Health Insurance better access to affordable health insurance and education aid country wide single payor health insurance Health Insurance for EVERYONE! Health insurance having a sliding scale. Health insurance to independent students. Make health insurance more affordable. A change I would really like to see would be for everyone to receive excellent dental and medical care, with little to no out-of-pocket expense because of insurance coverage. Available care for everyone. Lower rates on insurance better health (more affordable) insurance Better insurance access Everyone should be allowed to get affordable health and dental insurance. More affordable public health care. More availability for health/dental care. Access to low cost health care that won't put you into debt. Access access to programs that allows for low income residents to be able to afford health and dental care. Accessibility to services & incentives to use them. Affordable access to medical care for middle income people. better access continued opportunity to receive reduced cost health care at doctors offices and at Speare hospital Universal Health Care (single payer national program) Single-payer health care. a national health system easier access to sliding scale payment care. Have reduced health care structured to your income so everyone could afford not to be sick. Health care initiate a single pay inclusive health care system More access for those in need of services More payment plans to people who cannot afford health care and have bad credit. Especially for dentures for adults. Health care for everyone, I support president's health care reform. I would like to universal health care

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LOWER THE COST OF HEALTH CARE (1% of survey respondents)   The price of health care.  The cost of being healthy.  Cost  Cost of quality care.  Price of medical care; more clinics.  Lower health care costs. FREE HEALTH CARE (1% of survey respondents)   Free clinics.  Free dental care for adults with low incomes  Free health care for everyone!  The need to improve free health care and free transportation for seniors.  Free health clinic for the uninsured.

APPENDIX I

EXPANDED CAPACITY, QUALITY OF HEALTH SERVICES (8% of survey respondents)   A clinic every day.  A community health center  Access to a range of specialty providers. I am a part of the evaluation process and then I send families out with recommendations based on very limited resources especially in lower Grafton Co, where I also reside. Mental Health choices are limited and there can be wait lists, services for children outside of what the school provides means families traveling long distances (OT, speech, PT etc), Early Intervention services are sparse due to travel and availability of specialists traveling to a 'remote' location.  Access to health/relaxation facilites for non-PSU people  walk in clinic. smaller cost than er visit, but still available on the weekends, late evenings when something comes up. example, kid with strep throat. don't want to pay for ER visit, but can't wait until monday.  A place where people can go once or twice a month for their advice on their medical/mental questions or some type of group to help.  More doctors’ offices, or an easier way to get to already existing offices if you don't have transportation.  Add more walk-in clinics.  Added health care  Better access to medical specialists/treatments  there should be more dental and primary health providers for people who can't afford it.  Clinics who still treat ill patients.  Closer access to medical specialties.  Closer medical help!  community based clinic  the hospital  Speare Memorial hospital

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APPENDIX I

Dr's. - can't find a good one. expert doctors The health professional listen with great understanding and compassion to their clients. Go back to having a local doctor, when Speare Medical Assoc. offered a satellite office in Campton, the physicians seemed able to take more time to hear and understand my health issues. Health care availability Health care close by - more walk-in clinics. Revamp the funding and support system for the non-profit community so that there is more long-term sustainability of services and supports More opportunity for health care. Help NANA with donations and volunteer. Increase state revenue to fully support health services for the most needy. Increase support for at risk families. increased funding for needed services More & closer health providers. More care from service providers. more clinics More clinics or easier insurance qualification. more smaller clinics to treat common minor problems, for minor health issues that would help reduce travel time. i have to drive 1 hour each way for appt more walk in clinics that do not charge rates if you have gone to an ER More walk in health clinics and health education. More doctors More female doctors available. More female doctors. more free clinics More funding More health care clinics More inexpensive health care. More inexpensive/free early intervention health opportunities such as: vaccination clinics. more private owned offices, when they become too big, the doctor-patient relationship is diminished. more programs services available for young people and people with a disability, elderly

TRANSPORTATION (6% of survey respondents)   Access to public transportation (2 comments)  Access to transportation  Better transportation.  Transportation (2 comments)  transportation availability  transportation infrastructure so elderly could access services  Transportation needs and cost of activities for children.

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APPENDIX I

Transportation to access medical, mental health, and other services. Transportation to access medical,l mental health, dental care. Transportation to appointments and for home care. transportation to medical facillities Transportation!! Public transportation for everyone. Public transportation so the poor and working class citizens of our area can get to their appointments. Public transportation. (10 Comments) Put in public transportation. public transportation - we have none public transportation for elder adults to access medical professionals More public transportation. low cost transportation Create a place to call for transportation Increase public transportation opportunities I believe that transportation would be helpful for everyone even transportation to people to assist others in understanding their benefits. Have transportation - public or assign Volunteers to people in need. public transportation local taxis who accept EBT pay system $80 mo. in transport costs Easy, non-stigmatizing access to public transport for elders and families to help manage fuel costs and keep poor driving elders of the road.

RESOURCES FOR YOUTH, FAMILY, COMMUNITY SOCIAL & RECREATIONAL ACTIVITIES (6% of  survey respondents)   A bowling alley, a dance club, something to offer inexpensive social activities for young adults away from house parties.  Availability for youth to participate in a pro-social, healthy lifestyle activities  More work places. More places to socialize.  More expansive youth center that is geared to things teens want  youth activities at low/no cost  We don't have a youth center for teens to go to stay active.  Youth Centers (activities)  Parental involvement with children and more opportunities for youth activities. Kelley Park needs shade and seating, otherwise no one uses it during hot weather.  more community events and access to them (transportation)  more community centers and recreation opportunities  Affordable community activities.  Better affordable access to wellness centers like a YMCA  Better parks & rec.  build a community center  build a public recreational park with athletic fields including a track in Plymouth

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APPENDIX I

        ALCOHOL, TOBACCO AND OTHER DRUG PREVENTION & TREATMENT (4% of survey  respondents)   Accessibility to illegal drugs.  Encouragement of more people, especially younger people not to smoke or to stop smoking. Access to low cost or free smoking classes.  stop selling cigarettes!!!  stop smoking programs  Smoke-free environment  Smoking banned in public.  Quit smoking program  No drugs, more exercise.  No smoking in public anywhere, anytime. I'm tired of walking through 2nd hand smoke.  outlaw smoking  Better public education regarding alcohol & drug addiction. Especially prescription drug abuse.  Drug/alcohol treatment program.

Build sidewalks!! So you don't have to walk on roads or mud children need more activities to keep them out of trouble and healthy. baseball = expense sports = expense low income needs help for children, library need to offer local things, need to ask children their interests community center Community center for child and adult activities. community center with activities for all ages; a community pool and fitness center Community events for family and young children. Create YMCA - like facility Daycare & fitness class. Gardening More handicapped (wheelchair) accessibility to stores & shops in Plymouth, Lincoln, Woodstock, Meredith. Something like a YMCA. A lace to get fit and stay fit. I would appreciate opportunities to meet people in the community that are my age (40+). I would have fun activities at least 2 times a week at town hall. Something so people can get out of the house and interact with others. I would like to see more adult based activities available, such as dance classes, community sports, etc. that are not too expensive so that any social class can participate I'd make more community events that are geared towards people in their 30-40 range the music on the common is older music, and there aren't a lot of options, more activities that are more affordable More bike paths, skateboard parks, sidewalks. Increase community activities like the Plymouth downtown halloween parade. Opportunities to safely walk/ride bicycle/share rides to get places. More access to arts & cultural programs. More outdoor spaces. More local/available places to take pets.

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APPENDIX I

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Drugs delivery of drug education to be more effective, parenting education for 0-5 years old, the critical formative years improve drug and alcohol programs More strict regulations on underage and binge drinking at Plymouth State University. More things to do, there are too many teens and adult addicted to drugs and alcohol. We need to get them off the streets. drug and alcohol problems. More opportunities for work and lessening of chances for alcohol, drug from boredom. People need goals and a purpose. Drug treatment for youth. Cigarettes thrown. Close bars, make music in other places. Get rid of the pain care clinic that is used by so many people to get scripts for pills that they don't take but sell instead. Everywhere you turn in the newfound area you can find someone selling percocet, oxicotin, methadone etc. I personally have seen a huge increase in the availability and amount of people buying those meds illegally have a day treatment center put in. Shut down Hippey Hill I would have an affordable treatment Ctr. Obnoxious college students, Strict rule of noise complaints. Seriously pick up the beer bottles everywhere!!

EXPANDED ACCESS TO MENTAL HEALTH SERVICES (4% of survey respondents)  Accessibility to services for those who wish to be mentally well and to move forward into financial stability.  Better access to mental health programs.  Better mental health programs and for parents with behavioral health issued children.  services for people with disabilities/ mental health care  More, and more affordable, mental health care  Need more mental health resources locally.  More mental health support.  more open mindedness to mental health and well being  More Mental Health Centers, and Resources Centers  More mental health support for all ages and mentoring for young males.  More parental involvement and support for parents that are low-income and have children with special needs and or mental illness  Access to better/available mental health/drug & alcohol, abuse facilities.  I would increase availability of mental health services  I would want to see more help for old & young people who have mental illnesses & diseases.  Mental and general health coverage for all.

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APPENDIX I

mental health -- helping young and old full term living, safe environment, getting them the help and education that they need. safe from the streets. And homeless people in plymouth, seeing the guy we see all the time breaks your heart Mental health care Mental health services for you is very poor in this area. Mental health services provided in town. Mental health visitations at homeless shelter with people that can be trusted Having services come to you in situations such as the senior center and homeless shelter. Increase mental health services. More access to social services, e.g. counseling/mental health services, adult day care. More community mental health services for the population without health insurance. more extensive mental health care services for both teens and adults locally more for mental health more help for those with mental health issue EXPANDED HEALTH EDUCATION, OUTREACH AND WELLNESS PROGRAMS (4% of survey respondents) Add more wellness programs. advertising where services are available and what they are better education of services to locals A community outreach!! To better get health information out to people who may not have the means to find this out for themselves. To make sure the people that need help, the info needs to be put out there and on local TV. sex ed for teens. Education program for kids that have nothing to do . emphasis on promoting health vs treating illnesses simpler and user application for success, many do not know how to find service health education Health programs for community members. I'd educate the community more on all social issues. if there were more places to get help and more widely known to people promote healthy lifestyle choices, make them easy to learn about, access and use Increased educational resources. Parents who do not respect their children program to increase children's self esteem more education about health and wellness More free workshops and groups, nutrition, mental health, etc. Transportation to and from appointments. More info and referrals to meet needs of people. More opportunity for health care - prevention!

JOBS/JOB TRAINING (3% of survey respondents)   "jobs" for people to work in the u.s.a...don't send our life to other country.

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APPENDIX I

Beef up the vocational wing in H.S. so that kids graduate with a skill to support themselves. It is getting harder and too expensive for a lot of kids to get into college. Without votech they can't get good jobs. Easier access to jobs with benefits Education in our community for adults so that they can get better jobs and know more ways to find services that they may need! Education/job training. Good jobs I guess if I had to pick just one. Job opportunities Job training Job training availability. More job opportunities More job opportunities More jobs. School training for youths to get and keep jobs. The importance of job skills and the training The amount of people that are not working in this area and live on almost no money, jobs, clothing and health care. Increase in businesses to employ residents who could have health insurance More economic opportunity for more people Access to more employment opportunities within 1/2 hour commute. Wages If I win the lottery, I'll build a great business. So there's lots of employment.

COLLABORATION, COMMUNICATION, COMMUNITY INVOLVEMENT (2% of survey  respondents)   More participation from local hospital with physician practices in community events or patient care.  Ability for providers to link & communicate for clients/patients best interest - (talk to each other)  A more collaborative community approach to networking/support for parents across the socio/economical divides.  Strong leadership... optimistic and motivational leadership.  Team work.  Communication.  Get to know our neighbors.  I would have more time to volunteer.  More people worked together to help others when needed.  Increase connections for people with similar issues/ concerns for resource-sharing and problemsolving. Decrease gaps between "haves' and "have-nots"  More communication pro and con on health facilities  People being more open

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APPENDIX I

neighbors helping neighbors. Pointing people in the right direction to access resources to meet needs More meetings involving how we live and to improve life for us all.

ACCESS TO DENTAL CARE  (2% of survey respondents)   dental care for adults on medicaid  Dental care for adults with no insurance and no income  Dental care for everyone.  dental plans  more dental for low income. especially for children  More dentist to accept Medicaid  I would increase availability of dental services  Dental clinic for sure.  free or low cost dental care  more affordable dental health care  Better dental health & dental health insurance for low-0-income families. SENIOR SERVICES (2% of survey respondents)   Affordable housing for seniors to transition to.  Better senior housing.  Free exercise classes, more transportation for seniors.  Free health care for elders.  Food for the elderly and home care, sometimes they just need someone to talk to.  Pay more attention to the elderly, they are a wealth of information.  more elder help  Older people help  More home health aides for elderly/handicapped. ECONOMIC ISSUES/POVERTY (2% of respondents)   The need more of any subsidized housing available. Based on someones income - rent.  there are MANY families/people that fall through the cracks. They make too much to qualify and not enough to make ends meet  Community getting together and helping financially, emotionally, physically.  Everyone has tags on cars for disability, we need help getting $money to support family.  Have every business give an extreme amount of $, they write off other fortunes. Help people own houses. No one except the well-off has a house. We all live in subsidy and have no chance of ever living in our own home. It addresses a want, a need of a lot of people. My children deserve their own room that they can decorate and fell secure.  Reduce Poverty  Reducing the taxes would reduce a lot of stress among actual taxpayers. PSU paying its fair share for municipal services received would reduce the tax burden on the traditional residents.  Reduction in Poverty  Reduction of "disability" fraud claims/payments-would save Money for state, taxpayer etc!

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APPENDIX I

Remove assistance or make it a must for people to work to get any assistance. lower cost of electricity and fuel oil and gas more services to help people improve their circumstances not just service them

PUBLIC EDUCATION SYSTEM (1% of respondents)   Public education needs to have a major uplift. i believe the entire school day schedule should change and include all students to have therapy balls to sit on rather than chairs, regular and more frequent breads are taken, more education be taught outside the classroom, and that the teacher/student ratio could be approximately one teacher per four or five students.  Better education at school levels, all grades ever year. We should be teaching our kids about the value of money and how to pay cash/invest starting at a young age. Every grade especially 7-12 grade, bank advisors would be happy to teach this. Use community resources.  Financial support for our school districts  More emphasis on the importance of education! Stopping the 'politics.' DOMESTIC VIOLENCE PREVENTION (1% of respondents)   Crack down on domestic violence.  Start teaching respect classes in grade school and make it a requirement for graduating. People need to learn the importance of respecting themselves and others. Voices Against Violence needs to reach more people.  Provide more funding for DV/SA crisis services to provide services in outlying towns.  Increase funding for DV/SA crisis centers to do education & outreach  Increased support for DV/SA crisis services NOTHING/NOT SURE (3% of survey respondents)   All set  Honestly, I'm not sure right now.  I don't know (2 comments)  I don't really have a good honest answer.  I really don't know.  None (2 comments)  Not sure (4 comments)  Nothing (2 comments)  can't think of anything at present  hard to say. I don’t know what I don’t know  health has been fine for me OTHER   Weed out the folks that abuse the system, reach out and assist folk that are in true need! If folks can afford to smoke, drive a car, cell phone and are obese and drink they should not receive subsidy.  What new businesses we allow to move in. Family run businesses get plowed out when big business comes in. If bigger business is necessary or beneficial then awesome, but not another Chinese place or pizza shop or pharmacy or supermarket.

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APPENDIX I

winter - can't get outside to walk or play 1 on 1 with doctors, health care, etc. Put a Walmart in town. Thrift store prices at least 1/2 price for under income and food pantries serve food that a Senator would eat. a doctor that knew all about medicine, low income, mental health, disability problems Develop long term solutions to our needs with the environmental impact as the basis for the solutions to fulfilling those needs. We won’t be around to worry about the other issues if we don’t start to tackle this one and quickly. Better town water (tastes like bleach). Bristol Elementary School needs to be a one level school (physically), stairs are steep. understanding View easement tax cheap, affordable programs try to control careless driving of some young adults. Climate The water, so you can drink it. the weather Stop paying the medical/dental bills if you still have a new car, cell phone, fancy nails and smoke. Help yourself The natural spring where most people get their drinking water should be tested. Fire everyone, start over. Free health classes. Free McDonald's food. Me love double cheeseburgers and fish fillets. funding get rid of the sex offenders Health care money programs Less traffic Laws for health care. Nothing!! Except, have traffic lights in the middle of the square. More recycling sewage treatment plant smell downtown More help.

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Appendix II Parent Focus Group Notes
 

APPENDIX II
CENTRAL NH HEALTH PARTNERSHIP – COMMUNITY HEALTH ASSESSMENT WHOLE VILLAGE PARENT EDUCATION GROUP - FOCUS GROUP NOTES APRIL 18, 2011

The Central NH community health needs assessment included the facilitation of focus groups with targeted groups of community members. A focus group was conducted on April 18, 2011 with adult participants in a Parent Education group sponsored by Whole Village Family Resource Center. The focus group was facilitated by the Community Health Institute as part of a regularly scheduled meeting of the parent group and the evening included a family meal. A core set of questions asked about perceptions regarding community health strengths and gaps, awareness and impressions of existing services and programs, and thoughts on opportunities for improvement. The focus group lasted 80 minutes. All participants were informed that their participation was voluntary, confidential and that their names would not be recorded in any reports or associated with their responses in any way. Participants: The focus group participants consisted of 18 parents (12 females, 6 males). Participants had between 0 and 6 children in their families. Towns of current residence included Plymouth (9), Ashland (2), Campton (1), Thornton (1), Lincoln (1), Meredith (1) and Northfield (1); (2 unknown residence).
QUESTIONS & COMMENTS

1. In general, do you think the people in our community are in excellent, very good, good, fair or poor health? Question Summary: The general consensus of the group was that people in the area tend to be in fair to poor health. The reason for this perception, and the focus of most of the comments, is that health insurance is difficult to obtain and the cost of care is unaffordable. In addition to insurance for medical care, insurance for dental and vision care were also specifically mentioned. Participants agreed that the situation is better for children through Healthy Kids, but difficult for adults. Selected Comments (not a complete transcript): “I would say fair to poor health because it is so hard to get health insurance that I think a lot of people just skip it because they figure I’m not going to the doctor because I can’t afford it.” (Female; Ashland) “I have to agree with her I mean, because let’s face it you go to the doctor and you get this bill of like $2,000 and all they did was just go in there and say oh you’re sick.” (female, Plymouth) “And it is really hard to get insurance and medications are exceedingly expensive.” (female, Thornton)
Page 1 of 14 CNHHP Parent Education Class Focus Group April 18, 2011

APPENDIX II
“And up in Lincoln I don’t know of very many people or jobs that even offer insurance, especially dental you notice no one has dental insurance – no one that I’ve talked to.” (male, Lincoln) “Or vision” (Male, Lincoln) “Dental or vision are really getting hard to come by now.” (female, Plymouth) “Kids do get insurance through Healthy Kids, but most adults don’t have insurance.” (female, Thornton) “Or if they do have it, they have to pay a co-pay of like $150 or $200 bucks and it’s like you don’t have that money – it’s like when you get a spend down or something like that and it’s like you might as well not have it in the first place because you are going to spend the same amount.” (female, Plymouth) REDIRECTION TO PERSON WHO HAS NOT YET SPOKEN “I would go with fair to poor health. I don’t have insurance and I don’t even remember the last time I went to the doctor because of the cost.” (female, Plymouth) “You know we just had an incident because dental is not covered. He is on the Medicare program and that’s not covered. He had is teeth problem; teeth had to be removed; not covered and it slammed the family so hard and it was like oh my God what do we do. It was like $300 or something but luckily the dentist was able to help us and got it down to like $150, but it was still crazy high.” “It was $190 to have each tooth extracted, but he only charged me for 1 tooth instead of 2 because he was just a nice guy and I told him I didn’t have any money.” 2. What do you think are the most pressing health or healthcare issues facing our community? FACILITATOR: It seems like we have identified the ability to get health insurance, dental insurance and vision insurance as a major health care issue. Are there other issues that are pressing? Question Summary: Participants identified mental health care as a pressing health issue (6 participants) as well as substance abuse treatment (2 participants). Participants also continued to identify general dental care as a pressing issue as well as specific discussion of limited availability of oral surgery and orthodontic care (6 participants). Participants also discussed the limitations of specialty care associated with area hospitals – to include Speare Memorial, Franklin Regional and Lakes Region General Hospital. Participants discussed as a strength the level of communication and coordination between health care organizations. “The network that Plymouth has for social services is a lot tighter and a lot more in-depth than what the Laconia-Meredith area has . . . . So I definitely got to give this community ‘props’ for that . . . .” Communication and coordination between Genesis and Whole Village was also specifically mentioned as a strength.
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APPENDIX II
Selected Comments (not a complete transcript): Mental health <is a pressing issue> (unidentified person) “I was the owner of a company for about 16 years, but because of the economy it went belly up a about 2 years ago; since then I have been unemployed. I think the economy has a lot to do with what’s going on. The state of the economy right now is in really bad shape, especially around here. I think that is the prime factor – people have to survive. That is what I have been doing the last 2 years. I will do whatever I can do, because that is the only way to make money. That is my prime thing – trying to figure out how to make money. All the other considerations, health insurance, everything, it just doesn’t even matter.” “Another thing is cardiac care. There is not a good place close by. You have to go all the way down to Laconia for cardiac care. <Specific story of accident; trauma from “a couple years ago”> All they could do in Plymouth was stabilize him, that was it. They couldn’t operate or anything, because they didn’t have a cardiologist on duty to stabilize his heart. So they had to take a second ambulance ride – more money – to get him to Laconia which meant longer distance away from the family, away from where he should be when he is healing. They need cardiologists up there; that’s a desperate need.” “I don’t think it was a cardiologist – it was something else.” “I think mental health. I hope they don’t cut the budget on them, because a lot of people need Genesis as it is already and they can’t afford it and now they are getting another cut. I see Genesis and so do my children.” (Plymouth, female) “Ditto” (unidentified) “I go weekly, I mean it just really helps. Especially people who go through tons of grief and transition. To hear that they are getting a 50% budget cut. People already can’t afford the co-pay.” (Plymouth, female) We go to Genesis too. They are very good there, a very good facility. They seem to cooperate with these people here (Whole Village) to some degree, I don’t know how much. People from here know them and they know people from here. That’s the good thing – there is some community stuff going on there. To what extent I’m not really sure, but it seems like there is a good rapport there. “The network that Plymouth has for social services is a lot tighter and a lot more in-depth than what the Laconia-Meredith area has. There’s no communication between services (in Meredith) and there is here. So I definitely got to give this community props for that, where Meredith needs to step up.” (Plymouth, female – relatively new to area from Meredith)

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CNHHP Parent Education Class Focus Group April 18, 2011

APPENDIX II
“I live there now. It’s a quiet neighborhood, it really is. But communication is key – like between doctor’s offices and pharmacies.” (Meredith, Male) “While Whole Village communicates with Genesis really well here, Genesis is an entity onto itself in Laconia. They’re like an island. They don’t talk to anybody. There is no communication between services.” (Plymouth, female) “There is Genesis’ down in Laconia too. They don’t even talk to each other. It’s ridiculous.” (Plymouth, female) “Up in Lincoln-Woodstock area, it’s a small community, but there are no real mental health providers. It’s not really an impoverished area, but a lot of people are probably living close to the poverty level. It’s seasonal employment, so no one is getting any benefits. And there is no mental health. And I know with the economy the way it is people are just living season to season and there is a lot of stress there, but there is no way to really to cope with it.” (Lincoln, male) “I have to agree that we are better than most areas. I have family from down in New Jersey and they have absolutely nothing down there. We look like we are amazing compared to them, but there are still holes in it regardless.” (Ashland, female) “Some of them <holes> are really huge. Like the state’s version of dental care is severely lacking, because according to the state of NH teeth are not important. They do not pay for maintenance and upkeep on adults; they do not pay for dental appliances; they pay for extractions only and that’s it. (Other states) believe your teeth are a vital part of your health system and without your teeth being healthy, you’re not going to be healthy.” (Plymouth, female) FACILITATOR ASKS ABOUT EXPERIENCES WITH CHILDREN’S DENTAL CARE The kids’ dental is pretty well covered (general agreement among the group). They (Healthy Kids) just paid for my daughter to have a retainer put in and they paid for almost all of it. They do yearly dental cleanings, they do x-rays, fluoride treatment, sealants – all of it. They do really well with the kids, but it’s once you turn 18 and you’re out on your own if you don’t do what needs to be done, you are screwed. You are not going to have teeth by the time you are 30. (Plymouth, female) “The only problem with the kids dental that I have seen is if when an emergency comes up or if you miss a visit you have to pay $50 if you miss that visit and you can’t be seen again until you have that $50.” (Plymouth, female) “And they won’t transfer your records to another provider until your bill is cleared” (Plymouth, female) <Specific anecdote about child dental emergency –described extensive work done in Concord; “Plymouth couldn’t help us, because of the seriousness of the infection.”> (Plymouth, female) The lack of oral surgeons in the area is a problem (Meredith, male)
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APPENDIX II
“We are lacking in some of the specialty areas. I have to go to Concord or further to see an allergist and my daughter’s orthodontist is in New London.” (Plymouth, female) “I’ve had to go to Dartmouth to see an orthopedic surgeon for my daughter. You have to take her to Lebanon or Concord or somewhere else.” (Plymouth, female) “There is a dental office in Meredith, but they say they can’t do oral surgery there. They can refer you to somebody either to Laconia or there is a place in Center Harbor. But they are very few – hard to come by.” (Meredith, male) “If you are an adult, you can go to NH Technical Institute and get free or very cheap dental services by students. They are very slow however and it takes multiple appointments to go through the process, but it’s free.” (Ashland, male) “Another big thing is prostate cancer. There is nobody in this area. We have been having to run around like chicken’s with their heads cut off trying to find somebody. Have to go all the way to Dartmouth, or Massachusetts, or Concord or something. There is nobody in this area that deals with prostate cancer. It’s ridiculous.” “That’s the only thing about Speare. Speare is good at what they do, but they don’t really cover a lot of things; they are very limited.” They don’t have a lot of specialists (unidentified). Lakes Region General is pretty limited too. This area also is severely lacking in neonatal intensive care. (Plymouth, female) We have no Level 1 traumas, we have no NICU’s. (Plymouth, female) “Speare is a critical care hospital, like Franklin or Laconia, so they only see critical and emergencies.” (Plymouth, female) FACILITATOR ASKS QUESTIONS ABOUT REFERRAL COORDINATION AND COMMUNICATION . . . Depends on who is doing the referrals. Some of the offices are really good at making sure there is communication between the patient, primary doctor and the specialist. Other places it is like you have been handed off. (Plymouth, female) Tenney Mtn Internal Medicine – it takes them weeks just to connect you with the specialist, literally, sometimes months. And it’s ridiculous when you are in a bad situation. And also even the hospital takes hours – you go in the emergency room and you have a problem, wait 3 or 4 hours and will get to you. It’s like, OK I’m bleeding to death could you please hurry up, its’ ridiculous. (Ashland, female) REDIRECT TO FOLKS WHO HAVE NOT SPOKEN
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APPENDIX II
<shared specific anecdote that also questioned quality of care – took a week to diagnose strep throat> “One thing I am a little disgusted with in this area is their lack of help for people who are drug addicts. There is nothing here. And contrary to what Genesis says – that they have someone there helping them – my daughter went there, she was right in the middle of services and the woman just left and dropped her. I won’t tell you the repercussion of it, but it just left her hanging. There was nobody around. I had to drive her all the way to Dartmouth. I personally can’t do that. That’s a lot of gas. And the detox is a whole 30 days. I’m sorry, my daughter needs more than 30 days. <more specific anecdote essentially describing dual diagnosis – MH/SA>. There is nothing around here that can handle both MH and SA services simultaneously.” (Plymouth, female) “They should be handing off cases, not dropping cases. Somebody who has a drug issue can’t afford the trouble that is going to be caused by being dropped suddenly with no warning.” (Plymouth, female) “My daughter had gone to Horizons and she owed them money. And they kept saying well you’ve got to pay this. She doesn’t have any money and I certainly don’t have any to give her. So because of that she got no help and she went back down here and back to her old tricks.” (Plymouth, female) 3. Are you aware of anything new or different being done in our community in the past five years to address health-related issues? a. Are there any new or different services or resources available to you or your family that were not available five years ago?

Question Summary: A few participants discussed ‘Community Care/Health Access as a new and beneficial service. “They have a prescription program too. If it weren’t for them, my husband would probably be dead . . . . I have never been more grateful for anything in my life.” However, only 3 of 18 participants indicated that they were aware of this financial assistance program. Other participants mentioned Mid-State and the facilities at Boulder Point as something new that they were aware of. Other services mentioned included the Plymouth Regional Clinic, Family Planning, early intervention services through Lakes Region Community Services Council, a new sleep center, and food assistance. Selected Comments (not a complete transcript): Community Care (NH Health Access) through Speare Memorial Hospital. You can get health insurance and it is fairly easy. You can take it with you to the emergency room, to the OB/GYN office, to Mid-State. You get a laminated card. You can get a listing of where you can use it. It helps at Genesis. (Plymouth, female) “What is it?” (Plymouth, female) Also just opened new clinic up there on the cliffs – Mid-State, Boulder Point (Ashland, female)
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APPENDIX II
Orthopedics up there is pretty good, so is vision. (Plymouth, female) “There is also a clinic downstairs (Plymouth free clinic) on Tuesday nights with a sliding scale. But you can only be sick on Tuesdays (general laughter).” (Thornton, female) “There is a new sleep center in Plymouth which is kind of nice, because my husband always has to go to Concord.” (Plymouth, female) FACILITATOR ASKS AGAIN ABOUT HEALTH ACCESS – How many people are aware of the Community Care/Health Access program? <most people not aware; only about 3 of 18 indicated that they knew about it> “No idea”, “Not a clue”, “I have been on state assistance for a year and this is the first I’ve heard of it”, “what is the medical access part of it, I am not familiar with that?” “They have a prescription program too. If it weren’t for them, my husband would probably be dead. Heart medicine is insanely expensive and I couldn’t get his insurance any more. They paid for his medicine. I have never been more grateful for anything in my life.” (Plymouth, female) “To sign up for Community Care you just go to the hospital main entrance at the emergency entrance and you ask for Stacy Lembo and she signs you up.” (Ashland, female) She makes the cards right there in her office. (Plymouth, female) “I am covered through the state, but I have to pay a spend down. So if I want to go to Genesis, I have to pay a $150 spend down. I’m like, I want to go back to Genesis because I like it, but I don’t have $150 to give to them.” (Plymouth, female) Hannaford and Walmart both have $4 for 30 day prescriptions and $9.99 for up to 90 days. There is no sign-up either. They have a list and you have to tell the doctor. (Thornton, female) FACILITATOR PROMPTS TO THINK OF OTHER TYPES OF HEALTH-RELATED PROGRAMS OR RESOURCES THAT ARE NEW “They have family planning downstairs which is awesome. I took my daughter and we sat there for 3 hours, because they wanted her to be scared. They asked a bunch of questions. But they don’t charge teenagers for any birth control methods.” (Thornton, female) “My daughter goes to Lakes Region Community Services. She sees an early intervention educator who comes into the home and helps her with her speech and all that. It is a really good program. They are really amazing and they do a fantastic job. My daughter has progressed a lot since she has been seeing them. The only problem is that the service only goes up to age 3 and then the school system takes over. It should be extended until the age at which kids actually start kindergarten.” (Plymouth, female)

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APPENDIX II
“There is a referral program from the early intervention service to the school and (in my experience) they do a smooth transition. But the parent also has to immerse yourself in the record that is compiled at the early intervention to make sure that is passed along and the contact info is always with you and anyone who needs it. In this world, everybody has to have a release now.” (Campton, male) “I agree with that. They (Lakes Region Community Services) helped my daughter quite a bit and they need somebody else like that around here. The speech therapy at school is not helping her at all.” (Plymouth, female) “I think this relates to health and that’s the fact that there are good places to get food around here for free. I know of 2 really good food banks in the area and also if you have a child that is 5 or under, you can get free food from the WIC program. I am assuming everybody does that, but if they don’t know about that it is right here in this building. Because of our finances we don’t have a lot of money for food. I don’t think we have spent a dime for food in the last 2 years. We get EBT which is food stamps, we go to 2 food banks, and we get WIC and that covers just about everything we need. It’s amazing. We don’t spend any money for food. I wish they had something like that for gas (general laughter). Then we’d be all set. We’d be golden.” 4. What new programs, services or strategies or enhancements to existing programs, services or strategies would you suggest for addressing our most pressing health or healthcare issues?

Question Summary: Participants discussed the need for low cost recreational and exercise programs for children, but also for adults. The concept of a Community Center similar to the Meredith Community Center was raised by several participants. Both of these needs were also related to the need for more child care options for families, particularly to assist working families during the summer and school vacations. Transportation assistance for medical services was also mentioned as a need by several participants, although others noted being aware of resources to assist with transportation. Selected Comments (not a complete transcript): “Another thing is medical transportation.” <shared an anecdote related to not having a vehicle; eventually got assistance through senior center, what if I didn’t have that option?> (Ashland, female) If you have health insurance (participant means Medicaid), they have voucher transportation. There is an 800 number you can call and they will pick you up and drive you to the doctor. (Thornton, female) Case management through Genesis is extremely helpful including help with transportation. (Plymouth, female) Speare Memorial Hospital can help you with a ride. (Thornton, female)
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APPENDIX II
Need more low cost programs for kids, like sports and group activities. (Plymouth, female) “They need an after school youth center here.” <general agreement on this> (Plymouth, female) <anecdotal description of a youth program in Arizona> (Plymouth, female) The Kanc Rec Dept. up in Lincoln has a good sports program for kids like soccer. Some of the programs like karate and gymnastics you have to pay for, but it’s pretty good. (Lincoln, male) An indoor swimming pool would be good for the kids – kids like to swim and helps to keep them healthy. <general agreement> (Ashland, female) The college has a pool that anybody can use and they have open gym in the summer. (Plymouth, female) “The motel off exit 27 in Campton has a pool and they make it open to the public.” (Campton, male) Need more advocating and better management at homeless shelters. Every case there is different, but they treat you all the same. Need better social workers who have more empathy or who have better advice to give you. (Plymouth, female) “The one that is right here was just made about 5 years ago. Used to be downtown Plymouth. It was quite sad. My mother was in it.” (Plymouth, female) “There are programs around for kids, like dance studios and sports programs, but have you looked at the prices? Like the cost to get a kid into football; even if you are renting you are talking hundreds of dollars.” (Plymouth, female) “I think we need one place like a community center. A youth center – different than the teen center. Need an actual community center that would have a variety of programs for younger kids and families – after school programs, summer camps, all of that in one building. Like the community center in Meredith – their community center rocks.” (Plymouth, female) “This doesn’t relate to children, but in my case I have chronic pain. I know there are a lot of people around here that do. I’m supposed to stretch and do conditioning exercises and the state paid me to go all the way to Dartmouth and spend a month up there getting all this help because they wanted me to go back to work. I couldn’t go back to work anyway, but then they send you home and you are supposed to keep up the exercise. The stretching is fine to keep up, but try and find a way to exercise – weights or treadmill and all this – they have the gyms, but I can’t afford it. If I could have access to some of that – the equipment – I won’t get rid of my pain, but I could ease it a little a bit. I’m not the only one out there and nobody can afford it . . . . There is nothing in the area where you can go in and have someone guide you along the steps so that you don’t hurt yourself. That would really help and I know a lot of people in the same situation. Since they put in the pain clinic, there has got to be quite a few people up there.” (Plymouth, female)
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APPENDIX II
“It would make sense if they added that into the Medicaid or Healthy Kids type thing where at least even if it’s just a discount or X amount of visits – some way to work it in so that you get some sort of gym membership – because that would decrease the amount of health care they would be covering, because we would be improving our health.” (Plymouth, female) “That’s right. We have nowhere to go to do it.” (Plymouth, female) Child care up in Lincoln – the summertime through the rec dept you can get scholarships or grants – but it is 9 to 3, five days a week for the first part of the summer. Right now, it’s April vacation and my daughters are out of school and there is no place for them to go. (Lincoln, male) “It’s the same here.” (Plymouth, female) “It’s hit or miss. There are some areas that are better with the day care situation. Like the Meredith Community Center steps up and the do a lot of full-time or part-time camps during school breaks.” (Plymouth, female) “Plymouth Parks & Rec also does some things during school vacations.” (Plymouth, female) “The summer program is 9-3 for 5 weeks.” (Plymouth, female) 5. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the accessibility of health care services in the community? What thoughts or issues came to mind when you gave this rating? Question Summary: A plurality of participants rated accessibility as a 3 on a scale of 1 to 5, although 4 participants rated accessibility lower and only rated it higher. In general, participants discussed frustrations with long rides to services not available locally, long wait times in the waiting room, and some miscommunications with pharmacies. Selected Comments (not a complete transcript): Rating of 4 – 1 participant Rating of 3 – 6 participants Rating of 2.5 – 1 participant Rating of 1 – 3 participants “Up in Lincoln it is a 1” “Laconia is about a zero or a 1” “My daughter had her first doctor’s visit today. When we went first when as new patients, they were good about it. And she was seen today on an emergency basis, and she was seen right away. So I had a good experience. The doctor was at Mid-state – the pediatrician.”

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APPENDIX II
“The pediatrician at Mid-state is awesome.” (Plymouth, female) “I don’t have any problems getting an actual appointment. But they always tell you to arrive 15 minutes early which I do. But then I wait on top of that at least another 40 minutes to actually be seen and then they see you for a few minutes and then just go ahead and schedule you for another appointment. That has happened a few times this month already. They are over-booking, because they are trying to accommodate and they do things that they can’t accomplish.” (Plymouth, female) “I took my daughter over to a pediatric doctor at Dartmouth. Everyone says Dartmouth is one of the best hospitals and I believe that. But the doctor didn’t have the notes from my daughter’s pediatrician. She faxed it over there, but the doctor (at Dartmouth) never got to look at it. We weren’t even in the doctor’s office 10 minutes. We drove all the way to Dartmouth because her pediatrician referred her to Dartmouth. She had all of the paperwork that she needed, but the doctor never looked at the paperwork and we were in there for 10 minutes. I’m like, you aren’t helping me anyway. This isn’t doing anything to help her.” (Plymouth, female) “We had a similar experience for my daughter’s orthodontist. It’s like a 3 hour round trip ride for a 5 minute visit.” (Thornton, female) <anecdotal story of miscommunication between doctor and pharmacy> (Ashland, female) <another anecdotal story regarding pharmacy – an emergency Rx for an elderly family member – similar miscommunication; waiting for Rx; “definitely a lack of communication between doctor’s office and pharmacy”> (Meredith, male) “You don’t wait very long at Hannaford” (Plymouth, female) “Hannaford is pretty good” (Plymouth, female) FACILITATOR SUMMARY: So in general, your rating has to do with frustrations with long rides, long wait times in the waiting room, and sometimes pharmacies aren’t very reliable? (general agreement) 6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health care services in the community? What thoughts or issues came to mind when you gave your rating? Question Summary: With a rating of 4, nearly all participants rated the quality of services in the community higher than accessibility and two participants rated quality as a 5 (excellent). Some participants made distinctions between their physicians (“I love my doctor”) and their interactions with nurses and other office staff. Selected Comments (not a complete transcript): Rating of 4 – general, near unanimous sense of the group
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APPENDIX II
Rating of 5 – 2 “I’d say a 5. I love my doctor” (rating of 5) (Plymouth, female) “I’d say a 4. I have had good experiences.” (Plymouth, female)

“The people at Genesis lack in what you might call bedside manner. I think the individual people that work there are good at what they do, but the people who work for the office there are very lacking in people skills. Not at all fun to deal with”. “Sometimes it feels like they are just trying to get you out as fast as they can” <general comment, not specific to any particular agency> “The nurses seem to be lacking, but the physicians seem to be more attentive. The physician is amazing, but you spend a lot more time with the nurses than the physicians.” <general comment, not specific to any particular agency> (Plymouth, female) 7. In general, do you think people in this area enjoy a high quality of life? Question Summary: Participants discussed the physical environment, community safety and relaxed, peaceful communities as positive factors influencing quality of life and contrasted these factors positively with other areas of the country. The recent renovation of Pease Public Library was described as an important factor contributing to the quality of life in the area. Some participants discussed the poor economy and financial difficulties as factors negatively influencing the quality of life. Selected Comments (not a complete transcript): “Up where I live, it is what you make it. A lot of people don’t have a lot of money, but we are up in the White Mountains and there is a lot of stuff you can do that doesn’t cost money. Or you can sit inside all day and not do anything, so it is what you make it.” (Lincoln, male) “My neighborhood is fairly quiet too. It is a very relaxed area. We live near the woods, so in the good weather in the summer I will pull out my hammock and just sit there and read for a while. It is a very peaceful area. You can just sit there and relax.” (Meredith, male) “It just depends on what you make of it. Your definition of a high quality of life - mine could be different than anybody else. I think some people do, but the economy doesn’t make it easy to do anything that you might want to do.” (Plymouth, female) “You can do stuff that doesn’t cost much money, but when you are working like crazy to make what little money you do it takes a lot of time away.” (Plymouth, female)

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APPENDIX II
“If you got children with this economy it’s almost impossible. I make the best of it too. I have a huge play yard and I take them to the playground, but that’s about all you can do with them. I actually take them up on Saturday’s to the Mid-state parking lot. Nobody is there and I bring their little trikes and let them run around. It is what it is.” (Plymouth, female) “We do enjoy a fairly high quality of life because we can do things like that. There are a lot of other places where you would be afraid to take kids, because there is just too many people – I don’t know how else to say it. Other places there is a lot of crime, but around here there is a relatively low crime rate. I don’t know why that is, but I just get that impression that around here that is one of the main things we enjoy . . . . I just think we live a pretty good life around here in a lot of respects that we don’t even really appreciate until you go somewhere else. Like I have a lot of friends and relatives in the New York and New Jersey area and it’s totally different down there. We are so much better off. You have to watch your kids 24-7 down there.” FACILITATOR SUMMARY: So people tend to appreciate the environment and community safety (general agreement). Anything else? I really appreciate the Pease Public Library. There are people everywhere who have a negative outlook on life and do drugs and are just on this destructive path. But the Pease Public Library was just redone and it’s really nice. They have kids programs and the whole family can go there and enjoy it. (Plymouth, female) The college is opening a skate park. That’s going to be great. My kids are dying for that. (Plymouth, female) 8. Finally, if you were given 2 million dollars to spend on any one thing that you believe would contribute to improved health of our community, what would you want to spend the money on? Question Summary: Discussion focused on the need to invest in enhanced early learning services including sustaining Headstart and expanding Kindergarten hours. Other participants returned to the discussion of the need to subsidize participation in youth sports and other youth activities for lower income families. Finally, there was some discussion of the need to expand the capabilities (additional specialties) of the health care system (Speare Memorial specifically mentioned). Another participant noted the realities of what can be sustained in the area, but discussed the expectation that basic services should be more readily available and specifically mentioned general dentistry for children. Selected Comments (not a complete transcript): “I would keep the HeadStart program going.” (Plymouth, female) “I am with her.” (Plymouth, female) “Longer hours (for headstart).” (Plymouth, female)
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APPENDIX II
“I would do a definite improvement on the day care system.” (Thornton, female) “We need learning centers instead of day care. There is a learning center in Thornton – the Mad River Learning Center – where kids can start at age 2.” (Plymouth, female) Need a full day schedule; that’s more like a school schedule. (Thornton, female) “I would put it more toward extended day for kindergarten (plymouth elementary). My grandson is in the extended day and it costs $120 a month. That was a little mix up. When they told us about it, they never told us that it was going to cost anything. The children in kindergarten actually go to school less hours than the Headstart. It seems pointless to send them longer hours to Headstart and shorter hours for kindergarten when they have to learn so much for first grade. I would have to split the money between Headstart and Kindergarten.” (Plymouth, female) “I definitely agree with the Kindergarten. It is a huge area of importance.” (Plymouth, female) “I would invest in extracurricular activities. Like we discussed earlier how much equipment and program costs are for sports or dance. It would be like a special fund for families who can’t afford to buy the equipment; for kids who want to join these activities but their parents can’t afford it.” (Meredith, male) “I have had 5 kids who have all gone through school. I didn’t have the money (for the programs), but if you ask there are so many people that have scholarships or equipment lending programs.” (Plymouth, female) “A lot of people do donate equipment for like soccer or skiing even.” (Lincoln, male) “I would put the money toward expanding Speare Memorial’s capabilities – make it more like Dartmouth in Plymouth so you don’t have to go so far. If something really bad were to happen are you really going to have the ability to concentrate to drive all the way to Dartmouth. If there was somewhere close that had specialty care, it would be a lot safer situation, less stressful, and a lot better if you can visit your family and not have to worry about how to I get home or where do I stay.” (Ashland, female) “I just wanted to bring up a point about context regarding medical services. One thing that is for sure that everyone has said and I have been there – having to go to Concord just to get a child’s cavity filled. But it is a matter of scale. There are certain levels of medical services that it’s sort of a no brainer – they should definitely be brought up to that level for all access. But when you talk about medical specialists, the amount of money that person receives to be full-time in one particular area, I’m not sure that could happen here, but it is obviously something that is a need. There are basic services that are lacking even if you have insurance – I had to go to Concord to get my daughter’s cavity filled. I think that is a little bit silly.” (Campton, male) THANKS TO PARTICIPANTS - END
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Appendix III Service Providers Focus Group Notes
 

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CENTRA NH HEAL PARTNER AL LTH RSHIP – COMM MUNITY HEALT ASSESSME TH ENT REGIONAL SOC SERVICE PROVIDERS - FOCUS GRO NOTES CIAL OUP NOVEM MBER 4, 201 10

The Cent NH com tral mmunity heal needs assessment inclluded the fac lth cilitation of f focus groups with s targeted groups of co g ommunity members. A focus group was conduc m cted on Nov vember 4th, 2011 with soci service pr ial roviders wor rking in mostly the Gre eater Plymou and New uth wfound area. The focus gro was facilitated by th Community Health In oup he nstitute at W Whole Village Family Resource Center. A core set of questions asked about perceptions r f p regarding com mmunity hea strength and alth hs gaps, awa areness and impressions of existing services and programs, a thoughts on opportu i s and unities for impro ovement. Th focus gro lasted 60 minutes. A participa he oup All ants were inf formed that their participat tion was volu untary, confidential and that their nam would n be record in any re t mes not ded eports or associa with the responses in any way. ated eir Participant The focu group con ts: us nsisted of 10 individuals (8 females,, 2 males) re 0 s epresenting social service ag gencies in the region. e
QUESTION & COMM NS MENTS

1. In ge eneral, do you think the people in our com y t e mmunity a in exce are ellent, very y good good, fai or poor health? d, ir h Question Summary: The group felt th their com S e hat mmunity’s he ealth was on the “not-so-g good side”. T There is a define split in he ed ealth quality among differ socioeco a rent onomic group The diffe ps. erence between populatio was descr ons ribed as “tho who have it and those that don’t”,, and the “ha ose e e aves and the h have nots”. Th facilitator summarized this as “dich he hotomy in the health of th communi e he ity.” Selected Comments (not a compl transcrip ( lete pt): th mmunity is fa to poor if you include mental healt & behavio air f th oral “I would say the healt of the com health.” “I would say it’s not a dichotomy, but a dispar in the hea of the co rity alth ommunity.” 2. Wha do you think are th most pr at t he ressing hea alth or hea althcare iss sues facing our comm munity? Question Summary: The participants listed affor S rdability and access to hea althcare as m major issues, noting th Grafton County has on of the hig hat C ne ghest rates of uninsured c f children (0-18 8yrs) in the S State (6.7-9.6% Accessibil was a mai theme disc %). lity in cussed in ter of transp rms portation, chi care, and other ild issues tha affect an in at ndividual’s ab bility to get to a location. The issue of access and a o f affordability also extended to dental he ealth care and mental heal care. d lth
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Other issues discussed were nutrit d tion, obesity, and inadequ exercise,, specifically amongst uate hat ult ts children. Participants explained th it’s difficu for parent to take the first step to use good food and learn how to cook healthy me They add that people find com n k eals. ded mfort in packa aged, familiar foods, an that many families are too proud to go to the fo pantry. P nd o ood Participants r referred to th he “culture of poverty” and the “rura issue” as ca o a al auses preven nting needy p people from a accessing available services. Selected Co omments (not a complete transcript): “There is something so unfamiliar [to parents] about utiliziing good foo s s r ods.” “The “cu ulture of pove erty” prevent needy people in the co ts ommunity fro accessing available om g services. It is certainly an underlyin cause of poor health.” I y ng p ” “Since it is a rural com i mmunity, ma people ar unaware of services and support av any re f d vailable like HealthyK Kids.” “For som in Grafton & Coos Co me n ounty, pride affects their w a willingness to seek govern o nment handouts s.” “Self-emp ployed comm munity memb often assume that th will not q bers hey qualify for any services, or y r make just above the margin to qua t m alify.” “Co-occu urring disease es/disorders is also a pres ssing issue in the commu n unity for whic there aren a ch n’t lot of serv vices.” There is a new role of “support sp f pecialist” for Central NH Health Partn nership and it’s available to the whole community The support specialist works with p e y. w providers to h patients with any issues help they may have, such as transportat a tion, housing etc. Anoth new role i the “Famil Services g, her is ly Coordina ator” at Whole Village. 3. Are you aware of anything new or different b e being done in our community in e the past five ye p ears to add dress healt th-related issues? a. . Are there any new or different servic or resources available to yo or your fami that were no ces ou ily ot availab five years ag ble go?

Question Summary: The participants mentioned several initia S atives increas collabor sing ration and sh hared resources such as the Central NH Health Part s, e H tnership Selected Co omments (not a complete transcript): “Over the past two ye regionali ears ization of the prevention system has b e been big for our commun nity, m mation out the It contin ere. nues to grow..” and gets more inform “There is a lot more grant money coming in to our area for prevention services.” s g o r n
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We shoul work to make people more aware of the welfare system, for example the Plymouth A ld m m o e r e Area Commun Closet, a food pantry. nity . The StepB ByStep progr is new to the commu ram o unity and off fers, through a partnershi of provide h ip ers (Genesis, Family Reso , ource Center of Laconia, & Whole Viillage)(noteta could no clearly hea last r aker ot ar reference early childh e), hood mental health servi through a family assistance appro l ices oach. The Presc cription Card is another new program in the comm d n m munity that p partners with large scale h pharmaci to offer re ies educed cost prescriptions to uninsure people. p s ed The scho districts an schools in general, wh know welll what their s ool nd n ho students need have gotte d, en better at partnering with commun services to help familiies. A social service provi p w nity t ider noted “a real a improvem in the connection of services ava ment c f ailable in the community and schools” Transpor rtation Centra recently co al ompleted an assessment t identify tra to ansportation gaps and is in n the proce of develop a strateg plan. ess ping gic The Com mmunity Action Program runs a progr called Ra ram apid Rehousi Homeless Prevention ing n, which hel people who are home lps w eless or who are facing ho omelessness to stay in the homes, or get eir r back into housing as quickly as po o q ossible. Couch su urfers, people that are hom e meless but move around to different people’s cou m uches, are a h health issue as well, particula with the start of winter. It’s a segm of the p w arly ment population th tends to g hat get lost, beca ause they are not a family. The hom meless young adult population is anoth huge issue Many of th are livin from their cars. a her e. hem ng r The Rum mney Bible Co onference pr rovided housing for nine young adults last year. It is not known s n whether they will be providing this again this year. t p y “There is a 17-yr old problem whe people ar treated by the criminal system as ad s p ere re dults, but by the civil syste as childre em en.” “It is a bl lack-hole of service.” s A step fo orward in the community has been the integration of care. Gen e nesis is co-loc cating in prim mary care facili ities, which is a positive step in integrating mental and physica health care services. s s al Having case managers in these fac s cilities has als been a pos so sitive step. Nutrition Connection provides cooking lessons with pare and child n ns ents dren at variou locations. They us also do in ndividual out treach to pare who ma have a hard time taking that first step. ents ay d g 4. Wha new programs, ser at rvices or st trategies o r enhancem ments to e existing prog grams, serv vices or str rategies wo ould you su uggest for a addressing our most g pressing health or health h hcare issues?
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Question Summary: Ob S besity prevention services and program were a ma topic of d ms ain discussion am mong participan such as the HEAL pr nts, t rogram. Parti icipants note that low co activities utilizing the ed ost natural en nvironment, like hiking, are an excelle source of physical acti a ent f ivity. Expand organize ding ed sports for children wa also menti r as ioned. Participan expressed interest in a program th supported the cost of sports equip nts d hat d pment for activities such as bikin and skiing Improving healthy eatin through p ng g. ng programs tha teach adult to at ts s ggestion. cook was another sug Selected Co omments (not a complete transcript): ‘The com mmunity need programs that can help to increase low cost or n cost optio for physi ds p no ons ical activities.’ “How do we interject something physical into our lives?” o t p “How do you make physical activi o p ities fun to do for kids?” d 5. On a scale of 1 to 5 wher 1=Poor and 5=Exce re a ellent, how would yo rate the w ou e acce essibility of health care services in the co mmunity? f s What thoughts or iss came to mi when you gave this rating t sues ind g g? Question Summary: In general, the group rated accessibility o health care services a 2 Participants S g g of e 2. s emphasiz the challe zed enges of a rur setting. ral It was als mentioned that many parents have trouble mak appointm so d p king ments becaus they are to se oo busy jugg gling many ot ther things, li multiple jobs. ike j Selected Co omments (not a complete transcript): “The rura al-ness of the community prevents pe e y eople from ge etting where they need to go, whether it’s o r transport tation related or weather related.” d r “Some of the places that our clinic f t cians go, it’s pretty scary. ” “The thin that they’d like to do is maybe the thing that th can’t do, b ng d s hey because they can’t afford to y d lose their job either. So they have to choose be r S etween servic for their child and ma ces aking sure th hey have food on the tabl and a place to live, and that seems n right.” d le e not

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6. On a scale of 1 to 5 wher 1=Poor and 5=Exce re a ellent, how would yo rate the w ou e quality of healt care ser th rvices in th commun he nity? What thoughts or iss came to mi when you gave your rating t sues ind g g? Question Summary: In general, the group felt that the quality of health ca is a 4. Par S g g y are rticipants expressed that health care service providers are doing an in d e ncredible job with the resources availa able. Lack of dental service is the majo issue holdi the comm d es or ing munity back from a highe score. Ano er other issue is th limited ava he ailability of specialty serv vices. It was n noted that on positive as ne spect of healt in th the comm munity is the large practiti ioner networ for alterna rk ative and holi istic medicin ne. Selected Co omments (not a complete transcript): Speare Memorial Hos M spital offers a great quality of care, bu of limited r y ut range and spe ecialty becau of use its size. For example, people needi neurolog services ne to go else F ing gy eed ewhere. “It is incr redible what everyone is doing with th available s d he services. Gen nesis has divi ided its people into two! The reason I would scale it down fro 5 to 4 is t lack of de e om the ental services s.” eneral, do you think people in this area e y p t enjoy a high quality o life? h of 7. In ge Question Summary: Most of the grou was in agr S up reement that the region e t enjoys a high quality of lif h fe relative to the rest of the state/cou o untry, but there is a dispa arity between sections of the commun n nity. Participan felt that children have a better qua of life, e nts c e ality even though t they may be impoverishe ed. This was attributed to low crime rates relative to urban are as like Manc o r chester. How wever, particip pants t c c oved. Strengt thening the sense of felt that the sense of community is poor, and can be impro communi would hel to improv the quality of life. One way that it w ity lp ve would help is by improvin s ng the aware eness of rural poverty issu l ues. 8. Finally, if you were given 2 million dollars to spend on a one th w n any hing that yo ou belie would contribute to improv health of our com eve e ved mmunity, w what would d you want to sp w pend the money on? Question Summary: Part S ticipants had a variety of answers to th question.. Some felt th the mone d his hat ey would be be used to est owards impro oving the bui environme such as b ilt ent, building recr reational facil lities or affordable housing These types of projects can help to strengthen th sense of c g. he community. O One example was an indoo field house that would function as a health and wellness cen for w or e nter communi use. All participants ag ity greed that an built proje would also need to inc ny ect o clude an affordabl transportat compon le tion nent. One par rticipant men ntioned creat more/be ting etter transitio onal living pro ograms for pe eople who le eave institutio Another participant w ons. r wished to im mprove access to healthy lo food. Fin ocal nally, one per rson felt that the money w t would best b distributed directly to be d families for uses deter f rmined by th individual families. Thiis sparked dis he scussion from all particip m pants, and many agreed. Par y rticipants felt that the best way to dete ermine the us of the money is to liste to se en the peopl who are in most need of support, and use it in w that the feel will im le n o a ways ey mprove their lives.
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Appendix IV Local Faith Leaders Focus Group Notes
 

APPE ENDIX III X
LOCAL FAITH LEAD L DERS - FOCUS GROUP NOT S TES OCTOB 14, 201 BER 11

APP PENDIX IV X

CENTRA NH HEAL PARTNER AL LTH RSHIP – COMM MUNITY HEALT ASSESSME TH ENT

The Cent NH com tral mmunity heal needs assessment inclluded the fac lth cilitation of f focus groups with s th targeted groups of co g ommunity members. A focus group w conduct on Octob 14 with faith m fo was ted ber h leaders in the commu n unity prior to a regularly scheduled lo clergy as o ocal ssociation m meeting. The focus group wa facilitated by the Com as mmunity Health Institute and was hel at the Sta King Unitarian ld arr Universal Fellowsh A core set of questions asked about perce list hip. eptions rega arding comm munity health st trengths and gaps, awar d reness and impressions of existing services an programs, and i nd thoughts on opportu unities for im mprovement. The focus group lasted 60 minutes All partici d s. ipants were info ormed that th participa heir ation was volu untary, confi fidential and t their nam would n be that mes not recorded in any repor or associated with thei responses iin any way. rts ir Participant The focus group part ts: s ticipants consisted of 5 f faith leaders (pastors, de eacons, rever rends) from the greater Plym mouth area. Two particip T pants were in attendance for the dura n ation of the focus group, an others (thr participan joined th conversatiion late. nd ree nts) he
QUESTION & COMM NS MENTS

1. In ge eneral, do you think the people in our com y t e mmunity a in exce are ellent, very y good good, fai or poor health? d, ir h Questi Summary: Participants felt that gre tion s eater Plymout residents a in fair to good health th are h. They noted that th mediocre rating was due to inacces he d ssibility of he ealth insuran and poor nce menta health cov al verage. A participant note that one re ed eason for poor or lack of health insur f rance is tha many residents are selfat -employed or do various “odd” jobs t make a livi r to ing. Selecte Comments (not a complete transcript): ed ( “I sus spect that the a lot of people in the community that don’t ha health ins ere p ave surance…or specif employment that migh provide in fic ht nsurance. I su uspect that th are those in the here comm munity witho health insurance that don’t do the regular thing that those of us with out d gs st insura ance do- like get a yearly checkup, or follow up wiith a specialis for any pro e oblems.” “Acce to mental he ess ealth care is not anywhere nea where it shou be. Even th with insura and jobs a t ar uld hose ance are relucta to seek out mental health care they might need because t know that they might on be able to go for ant t they t nly o eight sessions [before their coverage runs out].” s r “In a rural commu unity it is har to be an rder nonymous [w mental h with health session Here if yo ns]. ou are go somewh for coun oing here nseling, it is hard to be dis h screet about that.”
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d hat sity d al erence so the ey “I had a person th worked at the univers that asked for a menta health refe could see someon outside of the universit noted on participan in response to a comme d ne ty,” ne nt e ent about the challeng of anonymity in a sma communiity. t ges all One participant co p ommented th dental ca is also a p hat are problem in th communit “a problem he ty, m you can see”, and that there sh c hould be a free dental clin like the h nic health clinic o Tuesday on nights. 2. What do you th hink are th most pre he essing heal or healthcare issu facing our lth ues comm munity? ol, Question Summary: Part S ticipants iden ntified addict to alcoho methamp tion phetamines, a tobacco, as and well as mental health disorders as the most pre m essing issues facing the co ommunity. T They noted th hat parishion come to them with ev ners vident addict and men health pr tion ntal roblems, but that it is diff ficult to address the problem since the emergency ro m e oom does no accept pati ot ients with me ental health problems unless they are suicidal or a danger to others. s o Selected Co omments: “I look at the price of cigarettes to t f oday and it ju blows me away…it just seems to m that tobac is ust e me cco a very strong addiction that has ec conomic consequences fo people tha just can’t a or at afford to be addicted and are. Tho economic consequenc reflect on the health o their famil The mon ose c ces n of lies. ney uld ared s buy r spent on tobacco cou be compa to things they could b for their families.” p w usional and re eally strugglin with that. I went with her to the E ng ER “I had a parishioner who was delu and they flat out told me that you ought to be able to bring people here with a men health g e ntal cy, w he t or else. emergenc but there is nothing we can do for her unless sh is a threat to herself o someone e The only thing it got her was an ap h ppointment at Genesis fa a aster. The do octor was rea dismissive of ally e n ctor trated but I s thought she didn’t ge anywhere n still et near her. I can understand why the doc was frust the qualit of care she wouldn’t ha gotten if she were a p ty e ave person with a broken leg.” 3. Are you aware of anythin new or different b y ng d being done in our com mmunity in the n past five years to address health-re s elated issue es? a. a Are there any new or diff t n ferent serv vices or res sources av vailable to you o or yo family that were not availa our able five y years ago?

Question Summary: The participants identified the expansion of services provided at Boulder Poi as S t n int a positive change. The also noted that the cha e ey d aplaincy prog gram at the h hospital is on 2.5 years o nly old, and is run by a social worker at Sp n peare Memor Hospital. Around eigh local faith leaders volu rial ht unteer for the pr rogram. Chap plains knock on patients doors and as if they wo like to ta Around 4 k sk ould alk. 40% of patient at Speare want to speak to the chap ts w k plain. Chaplai are restri ains icted from pr roselytizing a and speak to the patients in their own terminology. One particiipant noted t the Spea chaplaincy t i that are y
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Selected Co omments:

APP PENDIX IV X

egrated as pro ograms she has participat in previously. For exa h ted ample, notes from program is not as inte the chapl lain’s meeting are not reco g orded in the patients’ cha at Speare arts e.

“It seems to me that Mid-State He s M ealth has gon through ch ne hanges in the past few ye e ears. There is more of a connection or holism in the care you get betwee Mid-State and the reha facility [an n n u en ab nd other serv vices at Boul Point].” lder 4. What new prog grams, serv vices or str rategies or enhancem r ments to ex xisting grams, serv vices or str rategies wo ould you su uggest for a addressing our most g prog pressing health or health h hcare issues? Question Summary: Part S ticipants com mmented that mental heallth and addic t ction services had the gre s eatest opportun nities for enhancement. As the first po of contact for many r A oint residents suf ffering with t mental he ealth and/or substance us problems, the faith lea se , aders desire m more support in helping parishion access ne ners eeded service They sugg es. gested a locall care coordin nation call ce enter, a local psychiatri and great capacity for short term addiction t ist, ter f m treatment ser rvices. Additi ionally they n noted Speare Memorial Hos M spital’s inabili to care fo mental hea patients, unless a phy ity or alth ysical threat is present, to be a seriou limitation. t us Selected Co omments: “I would like some kind of central processing administrativ thing. One number I c call as a l ve e can parishion ner…to say th is the pro his oblem. Who should I take them to?” [ s e [Another par rticipant recomme ended 2-1-1 as a state leve resource.] a el “There ar universal suicide hotlin and that kind of thing but it woul be really h re s nes k g, ld helpful to hav ve one numb to call to get someon to tell me the best thing to do with this person r ber o ne t g right now…be ecause I don’t feel any kin of confide nd ence in diagn nosing a perso problem or needs b I on’s ms but might be the first pers aware of their proble I’m the o that need to be able to connect son f em. one ds them.” hat d s. nia “I wish th our local Genesis had one or two psychiatrists Right now you have to go to Lacon or do a video consultatio with a psy on ychiatrist in Laconia.” Th participant noted that p L he t psychiatrists outside of Genesis are too expensive for those without insu e e urance. “I wish th was som here mething you could tell a person with a addiction p c p an problem.” “When I talked to Wh Village awhile ago, th had a tw month wai period bec hole a hey wo it cause they we ere full. If a young mom comes in for financial hel and I can tell by lookin at her that she is using y c r lp ng g methamp phetamines, I’d like to be able to say to her ‘here is a check for the grocery store AND also I o s r can I help you make an appointme with an addiction cen p a ent a nter. Can we talk about yo addiction our n?’ There is nothing now expect send her to AA or Narc n w ding A… cotics Anony ymous.”
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icipant noted that he was unable to find an open s d s short term de etox program for his bro m other One parti who abus alcohol. He noted, “So here he is a year later an hasn’t do anything… doesn’t ses H nd one …it sound lik a solution for me.” ke “You wis there was a way to capi sh italize on the moment an say, ‘what can I do for you right now e nd w?’” “The only time I’ve ev been call in for an emergency it was a mental health eme y ver led t ergency- a woman had bipolar di h isorder and her delusions took a religi h s gious nature… Her daugh and husb … hter band were advo ocating for her…I though this was a woman in p h ht pretty good h hands. They w trying to get were o her admit somewh tted here…so they needed a vi y ideo conferen with a ps nce sychiatrist in Laconia. It f felt like…to get that level of attention she needed to have thos advocates with her, and she probab g n se d bly had health insurance. Because of the level of difficulty in se t d etting up this video confe s erence, the b bar was highe for getting psychiatric care. Even to get that lev of care it w the resul of having h er g o vel was lt her family the as advoca ere ates.” “If you wen to the hospit and you tho nt tal ought you had sprained your a sp ankle…would they have said, ‘no we don’t t treat sprained an nkles. Go away ay.’” “I just feel the standard of care is differe for mental health, and it m l ent h might not be if there was a psy ychiatrist availa lable in the comm munity.” One parti icipant noted that there isn’t enough time for him to be out in the commu d t m n unity. He additiona noted, “P of my job isn’t necess ally Part b sarily getting people into the church, b getting but people co onnected to services in th community s he y.” One parti icipant noted vandalism issues about a year ½ ago at his churc The vand were cou d i o ch. dals urt ordered to do volunte work in th communi He expre t eer he ity. essed concern about the p n parents and th heir own personal challeng that affec the family situation suc as unempl ges ct ch loyment. “Just abo everyone I know has two or three different thin they do… lot of it is selfout t ngs …a employm ment. They do whatever it takes…One way or the o o e other they ge through th day… they get et he y through the year. Eco t onomically th area is not healthy.” he One paris is working with Whole Village Fam Resource Center to d a project t address sh g e mily e do to poverty class differences. c A particip added, “We as midd class peop perceive t pant “ dle ple there to be lo of things in the area to do ots o that don’t cost much… go hikin and to the library wee t …we ng e ekly…One of the problem with addic f ms ction is that people perceive that there aren’t other things to do… One of th causes of a e a t … he addiction is m. municating w those th what hings boredom The problem is not a lack of things to do, but a llack of comm are.”

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Another participant echoe this statem and offe A ed ment ered the NH old home da and fairs as ays ex xamples whe people go and walk ar ere o round for fre even if the don’t have money to s ee, ey e spend on the individ activities dual s. There is muc more to do now than there was to do 40 years ago.” ch d t “T “S Socioeconom level affe attitudes toward famiily activities.” mic ects ”

 

[Another participant joins the con nversation.] 5. On a scale of 1 to 5 wher 1=Poor and 5=Exce re a ellent, how would yo rate the w ou e quality of healt care ser th rvices in th commun he nity? What thoughts or issues came to mind when you gave y s m your rating g? Question Summary: Par S rticipants felt the quality of “physical h t o health care” was excellen (rating of 4 5), nt 4but that mental health care was sev m h verely lackin (rating of 1 ng 1-1.5). One p participant co ommented th as hat a small to with limited services, the local ph own , hysician playe a valuable role in refer ed e rring patients to s other regi ional services as needed. 6. On a scale of 1 to 5 wher 1=Poor and 5=Exce re a ellent, how would yo rate the w ou e acce essibility of health care services in the co mmunity? f s What thoughts or issues came to mind when you gave t s m this rating g? Question Summary: Part S ticipants felt accessibility was predom minantly drive by health i en insurance sta atus. For those with insurance, accessib e bility was “gre eat”, but for those withou health insu ut urance acces to ss care is “re eally hard”. They felt that the solution to the prob T t n blem was bey yond the scop of the pe communi and neede national health reform One particiipant mentio ity ed h m. oned Grace C Counseling, a pastoral psychotherap practice ho p py oused at Plym mouth congr regational chu urch, as a ser rvice that off fered affordabl rates on a sliding scale to patients. Beyond inacc le s t B cessibility due to lack of h e health insuran nce, participan felt that services were generally accessible geog nts s graphically, e even for thos outside of se Plymouth area. h Selected Co omments: “[Accessi ibility] is grea if you got insurance, an it’s really h at i nd hard if you d don’t.” “What if you had to pay for a bab out of poc f p by cket? There a no other options. You either go to the are u o ER or you go into deb bt.” [Another faith leader from the HS joins the conversation It is noted that convers SA c n. sation is being recorded. .]

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le mmunity don’t have health insurance, I would say t h they will not be going to t the “If peopl in the com doctor ev if they ne to be going to the doctor.” ven eed Another participant noted that the community is fortunate to have Dar p n e y e rtmouth Hitc chcock in Hanover, “a world-cla facility”. , ass  Se everal echoed this sentim and adde that acces to hospital in nearby C ment ed ss ls Concord and d Manchester was also beneficial. M w

“Improve financial access to hea care cann be handle at the loca level. I thin it is a state or ed a alth not ed al nk e national policy decisio I actually think that th local healt care institu p on. he th utions are alr ready doing a lot tion to help po people get health car The docto have slidin scales. Th hospital ha a prescript oor g re. ors ng he as drug assis stance progra There’s the Plymouth regional cliinic. Some ch am. t h hildren’s care is free; for e example if your child needs to be evaluated for a learning d i r disability. I don’t think it’ the ’s communi ity’s fault.” [Another faith leader joins the con nversation. The facilitator reintroduce the project and notes th T r es t hat ersation is be recorded eing d.] the conve One parti icipant noted that there needs to be expanded pre d n e eventive servi vices, as well a more pers as sonal responsib bility for heal “There ar a lot of ov lth. re verweight peo in the community. W lack ople We preventiv care.” ve 7. What communit t ty-level impr rovements would you s w suggest for e enhancing o quality o our of life? Question Summary: Part S ticipants all agreed that tr a ransportation is a problem for the com n m mmunity. Wh hile they felt a bus might not be financ n cially feasible for the com e mmunity, they still felt tha something y at needed to be done to address the transportatio problem s o on such as bicyc paths or v cle vans. One participan recounted a story of a Plymouth resident that w nt walks from he church to Speare Mem er morial Hospital each day. Th participant also recom he ts mmended pro ograms and in nitiatives for increasing y r youth ent g b oot, nity n engageme including playgrounds accessible by bike or fo commun gardens in various communi ities, and free or low cost skiing. e t Selected Co omments: “Even a bus you pay a fare for is an improvem over no bus.” b a ment One parti icipant noted that church “extended family com d h’s d mmittees” are valuable reso ources for helping re esidents get to the doctor or the hosp t r pital. One parti icipant desire increased international exchanges w ed l within the co ommunity. H noted that He t perhaps global perspe g ectives could drive change in the deliivery of healt care, such as an increas es th sed focus on preventive care. c
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8. Finally, if you were given 2 million dollars to spend on a one th w n any hing that yo ou belie would contribute to improv health of our com eve e ved mmunity, w what would d you want to sp w pend the money on? Question Summary: S Several participants no that the would crea a “love ac oted ey ate ccount” or si imilar endow wment to pro ovide f fford care. Se everal particip pants also fel the fundin could be w lt ng well funding for residents who can’t af spent by enhancing Sp peare Memorial Hospital’s capacity to serve the m o mentally ill, th hrough the endowme of a psychiatric positi at the hospital, or hollding cells/be for ment health pat ent ion eds tal tients.

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Appendix V Focus Group Facilitator Script
 

APPENDIX V
Central New Hampshire Health Needs Assessment
Focus Group Guide
Facilitator script: Thank you for taking the time to meet with us today. The purpose of our discussion today is to ask for your thoughts and opinions about how area health and human service organizations can help improve the health and well-being of the community. Information from this focus group will be used by these organizations to develop plans and programs for improving the health of the community. Your responses will not be connected to your name in any way and will be combined with responses of other community members participating in other focus group discussions. To capture your feedback, we would like to record the conversation using both a digital recorder and hand written notes. This is done so that we can be sure that the information you provide is captured correctly. No names or identifying information will be transcribed from the tape or used in any report. Are there any objections to recording the discussion? Great. We’ll keep as close to your regular schedule for the parent education nights as possible, which means we will talk till about 7:15, take a break, and if we have any remaining questions finish those up after the break. Let’s start by going around and quickly introducing ourselves. If you can share your name, what town you live in and for how long you’ve lived in this area, as well as the makeup of your household- if you have any kids, if your parents live with you. I’ll start: My name is Arielle. I live in Manchester NH and I don’t have any kids. I work for the Community Health Institute which provides services to improve the health of communities in New England.

APPENDIX V
1. In general, do you think the people in our community are in excellent, very good, good, fair or poor health? 2. What do you think are the most pressing health or healthcare issues facing our community? 3. Are you aware of anything new or different being done in our community in the past five years to address health-related issues? a. Are there any new or different services or resources available to you or your family that were not available five years ago? 4. What new programs, services or strategies or enhancements to existing programs, services or strategies would you suggest for addressing our most pressing health or healthcare issues? 5. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health care services in the community? _____ What thoughts or issues came to mind when you gave your rating? 6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the accessibility of health care services in the community? ______ What thoughts or issues came to mind when you gave this rating? 7. What strategies or recommendations would you suggest for improving the quality or accessibility of health care services in this area? 8. In general, do you think people in this area enjoy a high quality of life? 9. What community-level improvements would you suggest for enhancing our quality of life? 10. Finally, if you were given 2 million dollars to spend on any one thing that you believe would contribute to improved health of our community, what would you want to spend the money on? THANK YOU VERY MUCH

Appendix VI Community Leader Interview Script
 

APPENDIX VI
Community Leader Name: Date & Time: Location: Interviewer: Tape Folder #:

Greater Plymouth Area Health Needs Assessment
Community Leader Interview Guide
The Central NH Health Partnership has asked the Community Health Institute to conduct a community health needs assessment of the Greater Plymouth and Newfound area. In addition to a series of key informant interviews we are also doing extensive secondary data collection, several focus groups, and a community survey. Then we’ll be aggregating all the information we’ve collected to produce an overall assessment, which will serve as the needs assessment required under community benefits reporting and will help guide the partnership’s and the individual organization’s activities. Two quick notes before we start: 1) Nothing you say in the interview will be directly attributed to you by quote or reference in any reports or documents. We’ll be combining the information with others to produce an overall assessment report of the community.

2) The entire community we are looking at is the Greater Plymouth and Newfound area, but if you feel that you can answers the questions more accurately looking at a subset of the area or even larger region that’s fine too. If you can just let me know how you define “the community” when thinking about community health so that I can make note of it.

APPENDIX VI
1. In general, do you think the people in our community are in excellent, very good, good, fair or poor health? 2. What do you think are the most pressing health or healthcare issues facing our community? 3. Are you aware of any promising new efforts being done in our community in the past five years to address health-related issues? a. Are there any new or different services or resources available to you or your family that were not available five years ago? 4. What new programs, services or strategies or enhancements to existing resources you would suggest for addressing the most pressing health or healthcare issues you mentioned?
5. Are there other concerns about the local health and human services system

that you feel are being overlooked? 6. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the quality of health care services in the community? _____ What thoughts or issues came to mind when you gave your rating? 7. On a scale of 1 to 5 where 1=Poor and 5=Excellent, how would you rate the accessibility of health care services in the community? ______ What thoughts or issues came to mind when you gave this rating? 8. What strategies or recommendations would you suggest for improving the quality or accessibility of health care services in your community? 9. In general, do you think people in your community enjoy a high quality of life? 10. What community-level improvements would you suggest for enhancing our quality of life? 11. Finally, if you were given 2 million dollars to spend on any one thing that you believe would contribute to improved health of our community, what would you want to spend the money on?
THANK YOU VERY MUCH. Here’s my card if you think of anything else you want to say, or if you need to follow up with me for anything.

Appendix VII Sample Community Survey
 

APPENDIX VII
COMMUNITY HEALTH NEEDS SURVEY EARN $$ FOR A LOCAL CHARITY!
Dear Community Member:  The Central NH Health Partnership is working to collect information about the  health of your community and we want to hear from YOU.   “Your community” can mean different things to different  people. For the purpose of this survey, your community  can be as big as the Greater Plymouth & Newfound area  or as small as your town. Answer the survey questions by  thinking about the area you see as “your community”.   For each local resident that completes the survey, the Central NH Health  Partnership will donate $2 to a local charity in need!  Please take 5‐10 minutes to give us your thoughts and opinions. The survey is  completely anonymous.  You will not be asked for your name or contact  information.    Your opinions on how we can build a healthier community are important!  Thank you very much for your time.    If you have any questions on this survey please call 573‐3341.  A summary report  of the survey results will be locally available.  Thank you again for your help.  CNHHP Partners

 Communities for Alcohol and Drug-Free Youth  Community Action Program, Belknap-Merrimack Counties, Inc.  Genesis Behavioral Health   Mid-State Health Center  Newfound Area Nursing Association  Pemi-Baker Home Health And Hospice  Plymouth Pediatrics and Adolescent Medicine   Plymouth Regional Clinic  Speare Memorial Hospital  Whole Village Family Resource Center  www.cnhhp.org

PARTNERS

COMMUNITY HEALTH NEEDS SURVEY  

APPENDIX VII

1.  What do you think are the most pressing  health issues  in your community today? (Check up to 5)  
  Access to dental health care    Access to mental health care    Access to primary health care                  Access to specialty services  Please specify: _____________________  Access to enough health insurance  Health care for seniors  Mental illness  (depression, anxiety, etc.)  Alzheimer’s  High blood pressure/heart disease  Diabetes  Poor nutrition/unhealthy food                                  Youth alcohol & drug use    Alcohol & drug use    Smoking/tobacco use    Cancer    Asthma    HIV/AIDS    Sexually transmitted diseases  Other infectious diseases  Prenatal care  Unplanned pregnancy  Teen pregnancy  Other    Please specify: ___________________                 

  Not enough exercise 

2.  What do you think are the most pressing  safety issues  in your community today?  (Check up to 5)  
People under the influence of alcohol or  drugs    Crime    Youth crime      Child abuse or neglect    Elder abuse    Rape and sexual assault    Domestic violence or partner abuse                              Discrimination based on lifestyle  choices or race  Identity theft  Being prepared for an emergency  Safety at public places  (parks, streets, etc.)  School violence  Bullying/cyber‐bullying  Other  Please specify: ___________________ 

CNHHP
Central New Hampshire Health Partnership

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COMMUNITY HEALTH NEEDS SURVEY  
         

APPENDIX VII

3.   What services or resources should we focus on improving to support a healthy  community?  (Check up to 5)  
                Public transportation  Job opportunities  Job training  Adult education & learning opportunities Parenting support  Quality child care  Youth programs and support  Education in the public schools                          Services for persons with disabilities  Substance abuse recovery programs  Access to affordable housing  Access to affordable food  Access to affordable clothing  Clean air and water  Sports and event opportunities  Arts and cultural events  Other    Please specify: ___________________                         

  Support for older adults 

4.   In the past year, have you or someone in your family had difficulty getting the  services you needed?     Yes (continue below)      No (skip to question 5 on next page)  4b. If yes, which services did you or your family have difficulty accessing?   (Check all that apply)  
  Primary health care  Specialty health care    Please specify: ___________________    Dental care for children    Dental care for adults    Mental health    Emergency health care                Social/human service agencies  Drug & alcohol treatment/recovery    services    In‐home support services  Long‐term care    (assisted living or nursing home care)  Other    Please specify: ___________________     

CNHHP
Central New Hampshire Health Partnership

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COMMUNITY HEALTH NEEDS SURVEY  
 

APPENDIX VII

4c. If yes to #4, why was it difficult to get the services you needed?  (Check all that apply)  
  Did not know where to go to get services Did not understand how to get the    service    Office was not open when I could go    Service I needed was not available    Had no way to get there    Waiting time to receive the services was  too long                                              Had no health insurance  Service was not accepting new  clients/patients  I was turned away  Could not afford to pay  Needed help with paperwork  Misunderstanding with staff  Language/cultural barrier  Did not want people to know that I  need the service           

  Had no one to watch my child    I was not eligible for services  Other    Please specify: ___________________         

5.   Which of the following programs or services would you or your family use if it was  more available in your community?  (Check all that apply)  
        After‐school activities for youth  Childcare  Adult daycare  Parenting support groups                                                      Fitness/exercise program  Nutrition/cooking program  Weight loss program  Health education  Lesbian, gay, trans‐gender and  bisexual support services  Diabetes support group  Mental health counseling  Drug and alcohol treatment  Drug and alcohol prevention activities  Stop smoking program  Medical services  Please specify: ___________________  Public transportation   

  Family counseling            Caregiver support  Education workshops for parents  Adult education  Job training  Information and referral 

  Stress reduction and relaxation classes    Community gardening  Other    Please specify: ___________________ 

CNHHP
Central New Hampshire Health Partnership

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COMMUNITY HEALTH NEEDS SURVEY  
       

APPENDIX VII

6.  What do you think is the best thing about living in your community?
 

    7.  What do you think is the most difficult thing about living in your community?
 

 

 

 

 

8.   If you could change one thing that you believe would contribute to better  health in your community, what would you change?  
 

          The following questions will help us to better understand the characteristics of your  community. This information will not be used to identify you in any way.            9.   What is your age?     18‐19    50‐64    65‐74    20‐24    25‐34    75 and older    35‐49                  10.   What is your gender?     Male    Female         

11.   About how many years have you live in the Greater Plymouth or Newfound  area?  
  ________________ years 

CNHHP
Central New Hampshire Health Partnership

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COMMUNITY HEALTH NEEDS SURVEY  
12.   What town do you live in now?  
                    Alexandria  Ashland  Bridgewater  Bristol  Campton  Danbury  Dorchester  Ellsworth  Grafton  Groton                       

APPENDIX VII

Lincoln  New Hampton  Orange  Plymouth  Rumney  Thornton  Warren  Waterville Valley  Wentworth  Woodstock  Other    Hebron  Please specify: __________________   Holderness                  For questions 13 & 14, a household is a group of people sharing a home and any income  earned with each other.  13.   Approximately, what is your annual household income?       Less than $10,000    $50,000‐ $74,000      $10,000‐ $25,000  $75,000‐ $100,000    $25,000‐ $49,000    More than $100,000          14.   How many people are part of your household?     ________________ people 

 
As a thank you for completing this survey, the Central NH Health  Partnership will donate $2 to a local charity in your area.  Please place the completed survey in the near‐by drop‐box, or mail to:  Central NH Health Partnership  c/o Community Health Institute, Attn: Arielle  501 South St. 2nd Floor  Bow, NH 03304 

҉

Thank you

҉ 

CNHHP
Central New Hampshire Health Partnership

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Appendix VIII Towns By Geography
 

APPENDIX VIII
Greater Plymouth Public Health Region Ashland Campton Ellsworth Holderness Lincoln Livermore Plymouth Rumney Thornton Warren Waterville Valley Wentworth Woodstock CNHHP Service Area Alexandria Ashland Bridgewater Bristol Campton Danbury Dorchester Ellsworth Grafton Groton Hebron Holderness Lincoln New Hampton Orange Plymouth Rumney Thornton Waterville Valley Wentworth Woodstock Grafton County Alexandria Ashland Bath Benton Bethlehem Bridgewater Bristol Campton Canaan Dorchester Easton Ellsworth Enfield Franconia Grafton Groton Hanover Haverhill Hebron Holderness Landaff Lincoln Lisbon Littleton Livermore Lyman Lyme Monroe Orange Orford Piermont Plymouth Rumney Sugar Hill Thornton Warren Waterville Valley Wentworth Woodstock 89,118

Towns In Geography 2010 Total Population

23,658

35,054

Data Source: Census 2010

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