Substance Abuse Wexford, Michigan

1. Prepared by:
Mercy Hospital Cadillac
Dawn Ewald, Community Outreach Director
Community Health Needs Assessment
Wexford/Missaukee Counties
2011

2. Community Health Needs Assessment 2011:
Improving the Health of the Community
Collaborative Partners:
District Health Department #10
Cadillac Area Health Coalition
Wexford-Missaukee Community Collaborative
CHNA Committee and Contributors:
Dawn Ewald, BSN, Mercy Hospital
Kevin Hughes, MA, Community Education Manager, DHD#10
Ken Nydam, MA, Human Services Leadership Council
Bob Doering, M.Div., BCC, Mercy Hospital, Community Benefit Officer
Kim Benz, Community Outreach Assistant
Jan Wiltse, PhD, Project Consultant
Kaitlyn Patterson, Project Consultant

3. Table of Contents
I. Introduction and Mission Review Statement 1
II. Retrospective Review of the 2008 Community Needs Assessment 3
III. Summary Observations from the 2011 Needs Assessment 5
IV. Community Description 6
a. Service area map 7
b. Profile of service area 8
V. Data Collection Approaches 14
a. Methodology 14
b. Community participation strategies 14
c. Other community data sources 14
VI. Findings from the Health and Community Data 15
a. Key community socio-economic factors 15
b. Key health indicator findings 15
c. Priority 1 Health Indicators 18
d. Priority 2 Health Indicators 20
e. Key environmental health factors 21
VII. Findings from the Community Input Process 22
a. Consumer health surveys 22
b. Public forums, Affinity focus groups, etc. 24
c. Physician input 24
VIII. Reflections on the Health Needs Assessment 25
a. The process: lessons learned and recommendations 25
b. Considerations for next steps 25
IX. Appendices 30
Appendix 1. CDC County Health Rankings, Wexford, Missaukee, Osceola 31
Appendix 2. Health Data Grid 32
Appendix 3. Community Support Survey 34
Appendix 4. Youth Advisory Committee Survey 38
Appendix 5. MI PHY – Wexford-Missaukee 40
Appendix 6. Priority 1, Priority 2, Health Indicators Grid 44

4. 1
I. Introduction and Mission Review Statement
From July 2010 through September 2011, a comprehensive community needs
assessment was conducted by Mercy Hospital Community Outreach Department, in
collaboration with members of the Cadillac Area Health Coalition and many other stakeholders.
A routine assessment of the health needs of the entire community, with special attention given
to the poor and underserved, is essential to fulfilling the mission of Mercy Hospital-Cadillac.
The Community Health Needs Assessment serves as a foundation and resource for Strategic
Planning and the Community Benefit Ministry Process. The following illustrates how the needs
assessment at Mercy Hospital – Cadillac relates to Trinity Health’s Mission Assessment.
Trinity Health’s Mission Assessment Process evaluates how current operations
(programs, policies, and procedures) are achieving, advancing or aligning with the
organization’s mission. It is designed to function as preparation for the Strategic Plan. Trinity
Health’s Mission Assessment is comprised of 17 mission standards. Standard #13 relates
directly to the Community Benefit Ministry Process and states “We develop strategic plans in
light of a thorough assessment of the health needs of the communities we serve.”
Trinity Health’s Integration Model
The Community Needs Assessment provides valuable information to the Strategic Plan
and Community Benefit Ministry process. The Community Needs Assessment looks at the “big
picture” of the community, with special attention given to the poor and underserved. It
focuses not only on physical health, but includes broader indicators of the health of the
community. This would include poverty, jobless rate, environmental health factors, and access
to health care, resources that promote good health, mental health, and other indicators or gaps
suggested by the community.

5. 2
The goal of the Community Needs Assessment is to maximize the effectiveness of
decisions regarding strategic direction and the dedication of programs and resources. A full
comprehensive Community Needs Assessment is conducted every three years within each
member organization of the Trinity Health System. Interim assessments are conducted to
evaluate progress in the intervening years. The current Strategic Plan and its related initiatives
will be reevaluated on an annual basis in light of ever changing community needs.
The Strategic Plan outlines key focus areas and organizational priorities that contribute
to vision and mission fulfillment specifically, care for the poor and underserved. Analysis of the
community needs enables identification of areas for future organizational and capital
investment.
The Community Benefit Ministry (CBM) Process includes programs and services
identification, evaluations and budgeting, which encompass data collection and reporting.
Included in the CBM are programs for the poor and underserved as well as the broader
community. These programs act to fulfill Trinity’s mission of community services and its
charitable tax-exempt purpose. The Community Needs Assessment provides information for
strategic priorities. The following flow chart delineates the process:

6. 3
II. A Retrospective Review of the 2008 Community Needs Assessment
The Community Health Needs Assessment conducted in 2008 was reviewed by the
Cadillac Area Health Coalition and a number of other agencies who established
recommendations to address the health gaps and trends identified at that time. The focus was
on policies, programming, and environmental changes. A summary of the recommendations,
goals, and outcomes follows, with information on how each has been addressed.
Based on the findings, four focus areas were identified: chronic lower respiratory
disease, chronic disease management, teen pregnancy, and substance abuse and alcohol.
Subgroups emerged. One of these was a specific focus on tobacco control, and the Tobacco
Coalition became a subgroup of the Coalition. Under those focus areas and subgroups, there
were many accomplishments. The chart on the following page illustrates specific goals under
each main category, resources found in the community, outcomes in alignment with Healthy
People 2010 objectives, and projected Healthy People 2020 Objectives.
When the goals and outcomes were reviewed, priorities emerged along with additional
priorities not originally addressed in the 2008 needs assessment. Examples are the increase in
charity care, bad debt, free clinic encounters, and affordable prescription medications. The
Medication Access Program (MAP) provided 510 recipients with free medications that would
retail at a cost of $1,930,688. This program has realized a 27% increase in use from 2009-2010.
Medication Access Program 2009 2010 2011*
Medications Dispensed 4,573 4,532 1,893
Dollar Value of Meds $1,856,308 $1,930,688 $819,692
Recipients 372 510 460
*Statistics are through June 14, 2011
Charity care was addressed by looking at the disconnect between the experience of the
‘homeless’ frequenting the emergency department and the disability application process. The
SOAR program partners a case manager with local human services organizations to ensure that
‘homeless’ adults who meet the medical diagnoses requirements receive access to housing,
health insurance, income, treatment and other services to begin recovery. Data indicate that
this program had the highest number of applications in this region with 65% approved within
68 days and a reimbursement rate since February 2009 of $219,382. According to a statewide
social security disability report, the greatest number of applications in our region were
submitted by the Mercy Hospital SOAR Case Manager shown below, with a 62% success rate
within 68 days. The approval rate has resulted in $219,382.00 in hospital reimbursement since
February 2009.

7. 4
Summary of the 2008 Needs Assessment findings by the Cadillac Area Health Coalition
Focus areas and
Goals
Assets Outcomes/2010 Objectives 2020 Objectives
Access to health
services: Poverty,
Uninsured
SOAR,CHW, Navigator,
Free Clinic, CPR-
survey, Programs, MAP
Tencon
Increase services for the uninsured
Results: achieved
Increase the proportion of
persons with health insurance
Maternal-Infant-Child
Health: Teen
Pregnancy
TPPI, Adolescent Health
Center, Care Linc
CHW
Reduce the rate of teen pregnancy
Results: achieved
Increase early prenatal care
Respiratory Disease
Tobacco Coalition,
Asthma Education,
Pulmonary Rehab
Pt. Centered Medical
Home
Reduce death rate attributable to
respiratory disease
Results: not achieved
Reduce activity limitations for
people with lung disease
Heart Disease and
Stroke
Cardiac Rehab
screenings, Education,
Patient Centered
Medical Home,
Physician Hospital
Organization initiatives
Increase the proportion of adults who have
their BP checked and can state what it is
Results: achieved
Same
Diabetes
Participate in Safe
Routes to Schools,
NMDI, 5210, Physical
activity programming
Worksite Wellness
Reduce the number of new cases of
diagnosed diabetes
Results: not achieved
Same
Mental Health:
Suicide
Suicide Coalition, Mercy
Collaborative: Anti-
bullying Campaign
Reduce the suicide rate
Results: achieved
Same
Oral Health
HSLC, United Way,
Fluoride Application Ed,
CHW
Establish free clinic/dentist relationship
Results: achieved
Reduce the proportion of
children with dental caries
Substance Abuse
Substance Abuse/MH
Task Force, NMSAS
Increase use of SAP, MAPS, and reduce
rate of opiate prescribing
Results: achieved (Wexford)
Reduce proportion of
adolescents who ride with
someone who has been
drinking
Key
SOAR Social Security, Outreach, Access and Reach NMDI Northern Michigan Diabetes Initiative
CHW Community Health Worker HSLC Human Services Leadership Council
CPR Coalition for Poverty Reduction SAP Student Access Program
MAP Medication Access Program MAPS Michigan Automated Prescription System
NMSAS Northern Michigan Substance Abuse Services TPPI Teen Pregnancy Prevention Initiative

8. 5
III. Summary Observations from the 2011 CHNA
The World Health Organization defines the Social Determinants of Health as “the
circumstances in which people are born, grow up, live, work and age, and the systems put in
place to deal with illness. These circumstances are in turn shaped by a wider set of forces:
“economics, social policies, and politics”. How these factors are interrelated is illustrated in the
following figure:
Because of the connection between these factors, an individual’s health cannot be
improved until the underlying problems are reduced or eliminated. Data are collected to look
at where the needs are found in a specific area. An example of an underlying problem that
needs to be addressed in Missaukee and Wexford counties is poverty. Poverty is the root
problem, impacting all areas of health, including substance abuse, unemployment, child abuse,
chronic disease management and prevention, mental health, obesity, and tobacco use.
The data collected in this needs assessment increased the awareness of the underlying
issues that directly impact the health of the community, including the relationship between
poverty, unemployment, and level of education. Many of these are included in the county
health rankings, showing the link between these factors when general health rankings are
provided. However, this may be misleading. Findings from county rankings appear that we
have access to resources. In reality, this may not be the case, as evidenced by the increasing
need for programs like Tencon and numbers of individuals without primary care providers
utilizing hospital emergency services for emergent and chronic disease management.
Within this process, benchmarks were established on the level of health of the
community. We concentrated on what we thought were the most pressing health issues,
Social Determinants of Health
8
Policies and Interventions
Biology
Physical Individual Socio-Economic
Environment Environment
Behaviors
Access to Quality Health Care

9. 6
focusing on the most vulnerable populations. The stakeholders and oversight committee
identified the gaps, barriers, the greatest health education and prevention needs and the top
social concerns.
When members of the Cadillac Community Health Coalition reviewed available data and
community resources, principal themes emerged. The process led to the identification of
leading problems in our community with those having the greatest impact as follows:
Poverty
Access to health care
Maternal-Child -Infant Health
Chronic disease management and prevention
Mental health problems, e.g. depression, suicide
Substance abuse/Tobacco and Alcohol abuse
The planning process then led to the following questions: Where are the gaps and
barriers in the management of chronic disease, addiction and mental health disorders? Could
care coordination with a focus on prevention and education result in improvements related to
health behaviors, obesity and physical inactivity?
IV. Community Description
a. Service Area
The service area for Mercy Hospital is shown on the following map. The hospital is
located in Cadillac, which is the largest city and county seat in Wexford County. Patients
needing services not available at Mercy Hospital are referred to the closest hospital, Munson
Medical Center which is 51 miles northeast or Spectrum Health System in Grand Rapids which is
90 miles south of Cadillac.
Wexford County has an industrial and recreational demographic base and covers
approximately 576 square miles. There are many opportunities for outdoor recreation.
Missaukee County is approximately 567 square miles, with farming and Christmas tree
resources. It is also known for tourism, with many inland lakes and rivers. The county seat in
Missaukee County is Lake City.

10. 7
Service Area Map for Mercy Hospital in Cadillac
Population: The 2010 population for Wexford County is 32,735 and Missaukee County is
14,849. This represents a 7.4% increase in Wexford County and 2.6% increase in Missaukee
County from 2000 to 2010, compared to the State population loss during that same time
period, as reported on the People QuickFacts from the US Census Bureau. Wexford and
Missaukee counties have both seen an increase in the 45-64 age group and a loss in the under
18 age group.

11. 8
b. Profile of Service Area
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Wexford County
Under 18 18-44 45-64 Over 65
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Missaukee County

12. 9
Marital Status: Families made up 72 percent of the households in Missaukee County. This
figure includes both married-couple families (59 percent) and other families (12 percent).
Nonfamily households made up 28 percent of all households in Missaukee County. Most of the
nonfamily households were people living alone, but some were composed of people living in
households in which no one was related to the householder.
Families made up 68 percent of the households in Wexford County. This figure includes both
married-couple families (53 percent) and other families (14 percent). Nonfamily households
made up 32 percent of all households in Wexford County. Most of the nonfamily households
were people living alone, but some were composed of people living in households in which no
one was related to the householder.
Vehicles: In 2010, 61% of Wexford and Missaukee County residents report owning their own
car. Transportation remains an issue potentially due to quality of the vehicles owned.
Social Security Income: Median income of households in Wexford County was $40,232.
Seventy-four percent of the households received earnings and 21 percent received retirement
income other than Social Security. Thirty-two percent of the households received Social
Security. The average income from Social Security was $15,087. These income sources are not
mutually exclusive; that is, some households received income from more than one source.
The median income of households in Missaukee County was $38,397. Seventy-three percent of
the households received earnings and 24 percent received retirement income other than Social
Security. Thirty-four percent of the households received Social Security. The average income
from Social Security was $15,850. These income sources are not mutually exclusive; that is,
some households received income from more than one source.

13. 10
Diversity
Wexford County Census 2010 Race
Data <>
Geography
Not Hispanic Hispanic*
*White Black* Indian* Asian Islander* Other* Two*
Wexford County 95.5 0.4 0.6 0.6 0.1 0.1 1.3 1.6
United States 63.7 12.2 0.7 4.7 0.2 0.2 1.9 16.3
<>
Geography
Not Hispanic Hispanic*
*White Black* Indian* Asian Islander* Other* Two*
Missaukee County 95.8 0.3 0.5 0.3 0.0 0.0 1.0 2.1
United States 63.7 12.2 0.7 4.7 0.2 0.2 1.9 16.3

14. 11
Education: In 2000, 82% of the Wexford County residents and 78.6% of the Missaukee County
residents over age 25 graduated from high school. Those residents over age 25 earning a
bachelor’s degree or higher is 15.3% in Wexford County, 10.2% in Missaukee County, and 21.8%
in Michigan. The 2010 Wexford and Missaukee County QuickFacts from the US Census Bureau
reported:
People QuickFacts Wexford Missaukee Michigan
High school graduates
% of persons age 25+
2005-09
85.7% 83.9% 87.9%
Bachelor’s degree or
higher, % of persons
age 25+ 2005-09
16.2% 12.2% 24.5%
The data show a slight increase in high school graduates and individuals with a college degree
from 2000-2010 in both Missaukee and Wexford Counties. In the Poverty Survey the
respondents reported that 39% have difficulty keeping a job primarily related to disability,
physical and mental health problems and transportation. Lake of education/skills was cited less
frequently.
Income and Poverty:
Business QuickFacts Missaukee County Wexford County Michigan
Per capita money
income in past 12
months (2009) dollars
2005-2009
$18,938 $20,446 $25,172
Median household
income, 2009
$38,657 $38,587 $45,254
Persons below
poverty level,
percent, 2009
15.0% 17.0% 16.1%

15. 12
Kids Count Reported in 2008:
Poverty – Ages 0-17

16. 13
Medicaid paid births: In Michigan, the percent of Medicaid paid births is 41%. The rate is
higher in both Wexford County (55%) and Missaukee County (54%) than the Michigan rate.
(MDCH, US census 2010).
Jobless rate: The following graph shows the jobless rate from 2000 to 2010. Wexford and
Missaukee Counties are both higher than the Michigan rate and the United States rate. The
2010 rate for Wexford County ranged from 14.9 to 19.8 and Missaukee county jobless rate in
2010 ranged from 13 to 20.
Uninsured Adults: Osceola (a small part of Mercy Hospital service area) reports a rate of 14%
uninsured adults and Wexford at 13% with a Michigan rate of 14%.
Uninsured adults ages 18-64 years old
Wexford County Missaukee
County
Osceola County Michigan
2011 County
Health Rankings,
BRFSS
13% 22% 14% 14%

17. 14
V. Data Collection Approaches
Methodology for data collection and community input approaches
Qualitative and quantitative data sets form the foundation of the Community Health Needs
Assessment. Data were collected from a variety of most recent sources to illustrate the most
comprehensive view of Wexford and Missaukee Counties. The sources include:
US Census Bureau, America Fact Finder “American Community Survey”
Michigan Department of Community Health
Michigan League for Human Services
Kids Count Data Center
MiPHY Data
District Health Department #10
Michigan Labor Market
Behavior Risk Factor Survey
County Health Rankings
Poverty Survey
Cadillac Area Youth Survey
Community participation strategies
A presentation was developed, including all the available health related data for
Wexford and Missaukee Counties. This was presented to the Cadillac Area Health Coalition,
offering representation from education, health department, community organizations, human
services, and coalition workgroups. The coalition collectively determined the highest priority
issues affection the health needs of the community. The Coalition will focus on these needs
during the upcoming years.
Other community data sources
Information was collected from a number of state and national sources as well as from
community partners on the Cadillac Area Health Coalition. The poverty survey and Cadillac
Area Youth Survey results were used, but may have limitations due to self-selection with certain
groups and because certain terms were not well defined.

18. 15
VI. Findings from Health and Community Data – Appendix 1 and 2.
a. Key community socio-economic factors affecting health
Social and economic factors: The following chart from the 2011 County Health Rankings
collected by the University of Wisconsin, shows how the counties rank among 82 counties in
Michigan, with Wexford County ranked 59 and Missaukee County ranked 48. Results are
compared to findings for Michigan. Violent crime is low despite high rates of poverty, minimal
social support and unemployment.
Wexford Missaukee Michigan
Social & economic factors Ranked 59 Ranked 48
High school graduation 85% 90% 77%
Some college 53% 46% 62%
Unemployment 17.6% 15.6% 13.6%
Children in poverty 24% 23% 19%
Inadequate social support 18% 11% 20%
Single-parent households 28% 26% 32%
Violent crime rate 286 120 536
b. Key health indicator findings
Access to care: According to the County Rankings, access to clinical care is illustrated in
the following chart. In general, Wexford County is ranked 2 out of 82 Michigan counties for
clinical care. Missaukee is ranked 65. Differences are seen in uninsured adults; 13% for
Wexford County and 22% for Missaukee County. A very large difference is seen in the primary
care provider rate with 660:1 for Wexford County and 2998:1 for Missaukee County.
Preventable hospital stays are lower than the Michigan rate. Diabetic screening and hospice
use are higher than the Michigan rate.
Wexford Missaukee Michigan
Clinical care Ranked 2 Ranked 65
Uninsured adults 13% 22% 14%
Primary care providers 660:1 2,998:1 874:1
Preventable hospital stays 53 53 74
Diabetic screening 90% 88% 83%
Mammography screening 73% 77% 69%

19. 16
In contrast to the County Health Ranking, the Behavioral Risk Factor Surveillance System
Survey conducted in 2010 interviewed adults in Missaukee and Wexford Counties, which
supplied different but similar information for analysis. Access to health care is included in the
Behavior Risk Factor Survey. Of those included in the survey, access to health care, no personal
health care provider, and cost is often higher than with Michigan residents, and the Missaukee
rate is higher than Wexford in all areas.
Wexford Missaukee Michigan
No health care coverage among those aged 18-64 years 22.5% 31.6% 15.1%
No personal health care provider 6.2% 14.0% 13.2%
No health care access during past 12 months due to cost 19.7% 13.3% 12.9%
No routine checkup in past year 24.8% 32.4% 31.8%
Health factors: In the County Health Rankings, Wexford County ranked 44 and Missaukee
County ranked 42 out of 82 general health factors. The rankings for health behaviors were 65
for Wexford County and 39 for Missaukee County. Specific factors are shown in the following
chart:
Wexford Missaukee Michigan
Health factors Ranked 44 Ranked 42
Health behaviors Ranked 65 Ranked 39
Adult smoking 27% 22%
Adult obesity 31% 32% 31%
Excessive drinking 16% 8% 19%
Motor vehicle crash death rate 19 13
Sexually transmitted disease infections 158 120 446
Teen birth rate 53 38 35

20. 17
The results from the Behavior Risk Factor Survey include information on health status. Personal
ratings of health status, physical health, mental health, disability, and life satisfaction are shown
in the following graph. Ratings are higher than in Michigan in several areas including no health
care coverage, no health care access or provider, overweight/obese, no leisure time physical
activity, diabetes, smoking, and no dental visit in past year. This is included in the following
chart:
Wexford Missaukee Michigan
Obese 37.0% 32.7% 35.6%
Overweight 39.6% 33.5% 30.1%
Inadequate fruit and vegetable consumption 80.1% --- 78.2%
No leisure-time physical activity 26.7% 34.4% 23.4%
Ever told diabetes 9.6% 19.3% 9.3%
Ever told asthma 11.1% 8.7% 15.2%
Still have asthma 8.1% 6.8% 9.9%
Ever told heart attack 5.2% 4.4% 4.7%
Every told angina or coronary heart disease 5.0% 8.2% 4.9%
Ever told stroke 3.9% 5.7% 2.8%
Current smoker 21.6% 26.4% 20.3%
Binge drinking 12.6% 18.6% 17.1%
Drove motor vehicle after drinking 2.7% 0.0% 2.5%
No dental visit in past year 30.6% 38.3% 26.0%

21. 18
c. Priority I Health Indicators – Appendix 6
Diabetes: The 2007-9 age adjusted death rate per 100,000 from diabetes in Wexford County
was 20.4, compared to 25.3 in Michigan. Numbers were too low to calculate the rate in
Missaukee County. Diabetes as an underlying cause of death in Wexford County is 88.2, in
Missaukee County is 103.3, and 79.7 in Michigan. (Michigan Department of Community Health)
According to the Behavior Risk Factor Survey, those who report they have ever been told that
have diabetes in Wexford County is 9.6%, which is slightly higher than Michigan’s percentage of
9.3%. In Missaukee County, the percentage is 19.3%. The BRFSS correlates well with
Missaukee County for diabetes as a cause of underlying death. The County Health Rankings
also reported high rates of diabetes screening in all counties. This could suggest that diabetes is
more readily diagnosed and potentially treated.
Cardiovascular Disease: MDCH reported an age adjusted rate of cardiovascular disease
mortality for 2007-2009. The rate reported for Missaukee County is 333.9 and Wexford County
253.6. Both counties are well above the Michigan rate of 276.2.
Teen pregnancy: When looking at teen pregnancy trends, teen births, and percent of births to
teens, in general the Wexford county rates are higher than Missaukee County and both
counties are higher than the Michigan rates. Teen pregnancies include births, miscarriages,
and abortions. Trend data on teen pregnancies is shown in the following chart.

22. 19
2000 2001 2002 2003 2004 2005 2006 2007 2008
Wexford 28.3 26.2 24.3 24.5 24.3 25.9 25.0 25.1 34.8
Missaukee 23.9 24.6 25.4 23.5 23.4 23.6 23.8 24.7 28.0
Michigan 15.9 15.5 15.3 14.9 14.4 14.0 13.8 14.1 18.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Percent of births to mothers who smokedduring pregnancy
Michigan League for Human Services
Teen Birth Rate: Rate of births to teens in Wexford County is much higher than the rate in
Missaukee County and in Michigan. The rates for 2004 to 2008 are presented in the following
graph.
Tobacco Use: According to the Behavior Risk Factor Survey data, smoking rates in Wexford
County are 21.6%, 26.4% in Missaukee County, and 20.3% in Michigan. County health rankings
indicate that the smoking rate is 27% in Wexford County and 22% in Michigan. Of even greater
concern is the percent of women who smoked during pregnancy. The percent in Wexford and
Missaukee Counties are much higher than the Michigan rate and the trend over time is shown
in the following graph.

23. 20
2004 2005 2006 2007 2008
Wexford 15.9 17.1 19.1 22.3 40.1
Missaukee 17.4 16.9 16.3 23.9 38.2
Michigan 21.8 21.9 21.9 22.5 29.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Percent of births with less than adequate prenatal care
Michigan League for Human Services
d. Priority II Health Indicators – Appendix 6.
Maternal characteristics: In 2008, births with less than adequate prenatal care are higher in
both Wexford (40.1%) and Missaukee (38.2%) than in Michigan (29.6%) with the greatest
increase from 2006 to 2009. Adequate prenatal care is as defined by the Kessner Index, a
classification of prenatal care based on the month in which care began, the number of prenatal
visits and the length of the pregnancy. The sudden rise (note 2007-2008) is reflective of a
change in birth certificates.

24. 21
Teen health indicators: The MiPHY data from 2009 gives an indication of student health
indicators in a variety of areas and among those in 7th
, 9th
, and 11th
grades. Areas of concern
include alcohol use, mental health and suicide, and drinking and driving/riding. A chart of the
findings is shown below.
e. Key Environmental health factors
Information from District Health Department #10 provides an overview of the environmental
health services. In 2010, there were 127 septic permits issued in Wexford County and 71 issued
in Missaukee County. Wexford County had 44 and Missaukee County had 25 septic failures.
In Wexford County, there were 141 well permits and 23 well inspections. In Missaukee County,
there were 103 well permits and 19 inspections.
Wexford County had 304 food operation inspections, 102 temporary food booth inspections,
and 9 reported cases of food borne illness. Missaukee County had 83 food operation
inspections, 33 temporary food booth inspections, and 1 reported case of food borne illness.
There were 71 animal bites reported in Wexford County and 41 bites reported in Missaukee
County.

25. 22
VII. Findings from the Community Input Process – Appendix 3 and 4.
a. Consumer health surveys
Poverty Survey: A survey was distributed from late October through mid-December (2009) by
more than two dozen human service organizations throughout the Wexford/Missaukee
Counties. A total of 965 anonymous surveys were collected from individuals using those
services and utilized in identifying the findings of this report. Two-thirds (69%) of the survey
respondents live in Wexford county, 26% in Missaukee County and 5% were identified as
residents of Osceola County. 77% of the demographic population was identified as female. It is
likely that the majority of the individuals are classified as living in generational poverty.
Characteristics of the respondents
69% were from Wexford County and 26% were from Missaukee County
77% were female
The two age groups with the most respondents were 25 years or less and 26-35 years
51% have children <18 years of age
Income
The vast majority were unemployed or unable to work
Estimated income of the majority of respondents (75%) is less than $10,000
This survey was completed by age groups 18 years old and above. The lowest income
was in the 35 years old and under age groups.
About 60% of the respondents say that they own a car
Education
Self-reported education attainment seems to correlate well with secondary data sets;
(US census) that is minimal college experience. This may be somewhat skewed due to
the residential status. Some may have recently moved to this area, or are transient.

26. 23
Compared to the Community Health Needs Assessment report, survey respondents are less
likely to have a 2-year degree or higher (13% vs. 23%), and more likely to have less than a high
school diploma (18% vs. 10%). 87% of the population have no college degree and 58% have no
experience at college.
Employment
The majority of the individuals who completed the survey were not employed. Those
that were unemployed by choice were homemakers, students, caregivers or retired. The
39% report having difficulty keeping a job because of a disability, health or mental
problems, or transportation issues.
Housing
Although only 4% of the individuals indicated an urgent need for housing, 1 in 5 do
indicate a need for assistance in home maintenance and repairs.
The majority live in a house but some are living in a house with more than one family,
most are renting. Individuals are looking for quality affordable housing.
Health
About half are most or completely satisfied with their life
60% good to excellent physical health, 55% indicate good to excellent mental health
Their best hope for improving their life is
 Finding a job
 Getting healthy and kicking bad habits
 Getting more education
 Finding affordable housing
Mental Health
Poor physical health is more frequent among those with less than a high school diploma (49%)
compared to those with a high school education or beyond (34%). Fair/poor mental health is also more

27. 24
frequent among those with less than a high school diploma (57%) compared to those with a high school
education or beyond (38%).
Additional help they need that no program is now providing
Dental care
Vision services
Medical care
Clothing
Transportation
Housing
Food assistance
Key Findings
Females are the majority of the poor and majority of those using services
Jobs: self-sufficient wage, disability, transportation
Most needed services are dental, vision, and medical
Barriers to improvement are health, money management, transportation, not wanting
or knowing how to improve life satisfaction, and the public perception of poverty as a
material problem with “relief” as the solution
Summary observations from Consumer Health Surveys
A survey was conducted of members of the Cadillac Area Health Coalition in April to
determine effectiveness of this group. The effectiveness aligns with the ability of the Coalition
to meet its mission to promote and support health related initiatives and collaboration The
results indicated high levels of satisfaction when rating items such as, Coalition had clear goals
and objectives, members understood the purpose, comfort with way decisions are made, agree
with decisions, well organized, and felt that the Coalition could achieve more together than
alone. Some members disagreed with the effectiveness of the leaders in motivating members,
utilizing their attributes, and providing guidance. Strategies have already been put into place to
address the negative responses from the survey. This needed to be addressed to increase
efforts to successfully implement action items and measure outcomes.
Summary observations from Public Forums; Affinity Focus Groups
A presentation of the data was given to the Human Services Leadership Collaborative
(HSLC). Input was received from human service providers, organizations, school
superintendent, and community health care organization representatives. Action planning and
ongoing status updates will be evaluated and reported on periodically.
Youth Advisory Survey – Appendix 4
The Youth Advisory Committee of the Cadillac Area Community Foundation conducts a
youth survey every three years. The 2010 survey was a random sampling of 242 students’
grades 6-12. The survey focused on issues and activities. The top three issues identified by
students are smoking, drug abuse and alcohol abuse. Students are most interested in more

28. 25
social and sports activities. Transportation to activities remains an issue to be addressed. The
data corresponds well with the 09/10 MiPHY results.
Summary observations from Physician Input
The physician PHO and other physician service groups have suggested gaps in services
and health priorities for the community. Physicians have agreed that the community must focus
on chronic disease prevention and management including mental health and substance use
disorders, stressing the need for mental health services for children, recruitment of primary
care providers including advanced care practitioners, promotion of self-management of health
and the advantages for the consumer and the community for providers that are a Patient
Centered Medical Home.
VIII. Reflections on the Health Needs Assessment
a. The Process: Lessons learned and recommendations for future CHNA
It is critical to have representation from community groups on the Coalition to gain
perspective and data from a variety of sources. Also, it is important to simplify the process. In
our communities, we need more input from Missaukee County. They have an independent
attitude and have been unwilling to participate in the process. Results from the needs
assessment show that work is needed to address problems such as lack of transportation. We
also need to focus on increasing problems due to diabetes and many behaviors that contribute
to chronic disease prevention and management.
Our goal is to fully involve the community to do what is best for local organizations. This
will be accomplished through potential partnerships with other organizations and their boards.
It is imperative that local community involvement is maintained. Currently this includes the
Cadillac Area Health Coalition which has representation from the YMCA, District Health
Department #10, Baker College, Mercy Hospital PHO, Cadillac Public Schools, Wexford-
Missaukee Intermediate School District and quarterly attendance from various for profit
organizations. In addition to consumer surveys, it would be beneficial to have formal focus
groups. A private company may be utilized to obtain data in coordination with Trinity
opportunities. The community collaborative also provides very valuable information,
community support and broad area representation.
b. Considerations for next steps
1. The Community Needs Assessment Process. Utilize the above groups to
present the data. Collaborate with other member organizations that have
completed this process or are in the process of completing, to use the same
state and national data. This avoids accession of materials by multiple
individuals. Establish community benefits board involvement at the onset of
this process. Keep board members fully engaged in the strategic plan through
ongoing evaluation strategies which are focused on the goals.

29. 26
2. Poverty and unemployment. Poverty and unemployment both in Wexford
and Missaukee counties has steadily increased according to multiple data
sets. People with low incomes or families living in poverty are more likely
than those with higher incomes to become ill and suffer from chronic
diseases. The research has documented a stair step pattern of worsening
outcomes from rich to poor, with the poor more likely representing the
largest proportion of preventable causes of disease; smoking, obesity and
lack of physical activity. The Human Services Leadership Coalition considers
this a top priority. Action planning and outcome measures will be designed
by the Coalition for Poverty Reduction and supported by the Cadillac Area
Health Coalition.
The following quote illustrates how access to care and community resources can impact
health problems in the community through the use of the area free clinic. "I needed to be
tested for diabetes and I couldn't afford insurance’, states “Joy”, wife, mother, and full-time
student. "Someone told me about the clinic. After my diagnosis for type 2 diabetes, I got
supplies, education, and most important ease of mind"
Urgent Care Clinic 2010 2011*
Patient Visits 1,393 993
Unique 944 485
Prescription Vouchers 55 29
Dental Vouchers 66 16
3. Access to Health Care. While the county health rankings of 2010 suggests
highly effective clinical care in Wexford county (2 out of 82), its neighbor
county, Missaukee is in the lower third of the county rankings. The rural
populations identified in our service area access services in Wexford County
due to minimal availability. This situation is compounded by limited

30. 27
transportation services. This is a major contributor to health disparities. It
isolates low-income populations from early access to health care, postponing
both prevention and management of health conditions and using much of
their budget on vehicle expenditures.
Primary care provider offices are currently not accepting any new patients.
This includes our local federally qualified health center. The emergency
department and free clinic are being inappropriately used for chronic care or
the patient must travel long distances to obtain care. Many different
evidenced based programs are being reviewed for potential solutions. Offices
participating as patient centered medical home will continue to be
encouraged.
4. Maternal-Child-Infant Health (the most vulnerable). The well-being of
mothers, children and infants determines the health of the next generation.
Improving the health of our future generation reduces future health
challenges. Healthy People 2020 recognize many factors that affect the
health of the mother, infant and child.
According to Kids Count 2010, there are 23.9% children ages 0-17 in Wexford
County living in poverty. Missaukee County has a 22.8% rate of children
living in poverty. These rates compare to a Michigan rate of 19.3%. The
National Center for Children in Poverty (NCCP) in July 2011 reported “the
relationship between socioeconomic status and health is one of the most
robust and well documented findings in social science. The relationship is
almost reciprocal, as poverty detracts from resources used to maintain
health, while poor health detracts from educational and employment paths
to income mobility”.
NCCP substantiates that one of the most prevalent risks to neonatal health is
smoking during pregnancy. Both Wexford (34.8%) and Missaukee (28.0%)
have a higher rate than Michigan (18.0%) for births to mothers who smoked
during pregnancy. The MiPHY conducted in both Wexford and Missaukee
reveal that smoking is a problem in high school as does the Youth Advisory
survey. This data is consistent with research which finds the highest
prevalence of smoking in low-income, less educated, working class white
adults. Other high needs, issues in this population and validated by various
data sources include less than adequate prenatal care, poor oral health,
childhood obesity, depression and an ongoing teen pregnancy problem.
5. Gaps in available services. The current demographics have suggested that
the older population represents the only remarkable population shift in
Missaukee and Wexford counties. The challenge then lies in identifying
Senior needs and matching them with availability of providers. The Physician

31. 28
Hospital Organization, affiliated with Mercy Hospital, provides an organized
approach for physicians and hospitals to work together. In addition, because
all of the major practices servicing the Cadillac area, patient centered
medical homes, the senior population will be a full-fledged participant in
their care having the knowledge, skills and opportunity to effectively partner
to maintain and/or improve health. This service aligns the practice well with
2011 demographic implications of this assessment.
Collaboration has been pivotal and evident utilization of available resources
in this community.
6. Chronic disease, coordination of care, health behaviors. As the population
of the Cadillac area ages and life expectancy and obesity increases, higher
rates of chronic disease are sure to follow.
According to the Centers of Disease Control and Prevention, in 2007 29% of
adults in Michigan reported having hypertension, 95% reported being
diagnosed with arthritis, 21% of adults reported being current smokers, and
64% were overweight or obese. In addition, a 2007 Milken Institute study
found that the annual economic impact on the Michigan economy of seven
common chronic diseases is more than $48 billion, comprised of $37.9 billion
in lost productivity and $10.6 billion in potentially avoidable treatment
expenditures (not taking into account the secondary health problems they
cause). Chronic disease is a costly and burdensome problem for the state of
Michigan and certainly for the Mercy Hospital service area.
Increasingly, health care experts are calling for care management programs
to be integrated into the clinical setting, using face-to-face communication, a
team approach to care delivery, and incorporating the principles of self-
management. Inherent in the notion of transferring care management into
the clinical setting is an emphasis on practice redesign and a complete
transformation of the care delivery model.
Care coordination delivers health benefits to those with multiple needs,
while improving their experience of the care system and driving down overall
health care (and societal) costs. Communities where health care and housing
providers have partnered together have seen dramatic improvements in
health, costs, and patient experience, including increased engagement in
preventative care, increased management with self-care, higher self-
reported health status, and dramatic decreases in individuals’ health care
costs.
The Patient Centered Medical Home is an effective and structured way to
begin practice transformation activities. Elements of the model, including

32. 29
population management, the use of evidence-based guidelines, disease
prevention activities, coordinated care management, and the use of clinical
information systems, are often associated with effective care for chronically
ill patients. Mercy Hospital, partnering with the PHO will promote care
coordination as a method for managing the current and future populations
with a chronic condition.
7. Mental health problems, substance abuse: A rigorous literature search has
suggested that one in four patients admitted to a hospital has a primary
diagnosis related to mental health/substance use disorders or a condition
exacerbated by a mental health/substance use disorder. The impact on the
population both in the United States and in the Cadillac area is enormous.
The Substance Abuse Mental Health Services Association (SAMHSA) in their
“Leading Change: A Plan for SAMHSA’s Roles and Actions” reported that:
The annual total estimated societal cost of substance abuse in the
United States is $510.8 billion.
By 2020, behavioral health disorders will surpass all physical diseases
as a major cause of disability worldwide.
In 2008, an estimated 9.8 million adults aged 18 and older in the
United States had a serious mental illness. Two million youth aged 12
to 17 had a major depressive episode during the past year.
In 2009, an estimated 23.5 million Americans aged 12 and older
needed treatment for substance use.
Half of all lifetime cases of mental and substance use disorders begin
by age 14 and three-fourths by age 24.
Analysis of community data such as the MiPHY, BRFSS and Community Poverty
survey along with local chart reviews substantiated the problem locally.
1. Prevention and Awareness: Participate and support Northern
Michigan Substance Abuse Services “Prescription Drug Abuse/Misuse
Reduction” initiatives.
Support community protective factors activities.
Reinforce TIPS training for all seniors in area high schools.
Conduct physician prescriber practices performance improvement
activities with a focus on policy establishment, patient contracts, pain
management training, MAPS utilization, drug testing, law
enforcement relationships and prescription refill procedures.
Educate community leaders.
Support parenting programming.

33. 30
2. Management
Consider employing or establishing a pilot for a Community Health
Practitioner for patients with mental health/substance use disorders,
as a community case manager to reduce inappropriate hospital
admission, encourage mental stability and maintain longer periods of
sobriety.
8. Ongoing work: Each of the priorities requires or has completed action
planning potentially in alignment with the overarching goals of Healthy
People 2020. Each action plan will develop:
1. Vision: Why is the plan being established.
2. Goals: What do we want to happen?
3. Establish objectives and strategies: how will we know whether
we have reached our goals – who, what, when and where and
how.
4. Measure progress: How effective have we been?
The action plans will be used by community groups to measure changes in the
health status of our residents or make adjustments if needed.
IX. Appendices
The following pages contain supporting documentation on our findings.

34. 31
Appendix 1

35. 32
Measures Wexford Missaukee Osceola State US Source
Health Outcomes
Mortality
Years of potential life
lost/100,000 pop.
8,548 6084 7,599 7,387 5,564 National Center for
Health Statistics
(NCHS)
% Adults reporting fair or poor
health
19% 14% 15% 15% Behavior Risk Factor
Surveillance System
(BRFSS)
Avg. physically unhealthy
days/month
3.8 3.4 3.7 3.5 2.6 BRFSS
Avg. mentally unhealthy
days/month
4.2 3.5 4.9 3.7 2.3 BRFSS
% Live births with low birth
weight <2500g
6.7 5.4 6.3 8.2 6.0 NCHS
Health Factors
Health Behaviors
Tobacco: % Adults reporting
currently smoking
27% - - 22% 15% BRFSS
Diet & Exercise: % Adults
reporting obesity (BMI > 30)
31% 32% 31% 31% 25% National Center for
Chronic Disease
Prevention & Health
Promotion
Alcohol Use: % Adults
reporting binge drinking
16% 8.0% 15% 19% 8% BRFSS
Motor-vehicle related
mortality/100,000 pop.
19 - 18 13 12 NCHS
Hi-Risk Sexual Behavior:
Births/1,000 teen females,
ages 15-19
53 38 40 35 22 County Health
Rankings
New Chlamydia cases/100,000
pop.
158 120 122 446 83 NCHS
Access to Care: % Adults 18-
64 without insurance
13% 22% 14% 14% 13% County Health
Rankings
Appendix 2
Exhibit 4: CDC County Health Ranking Data Grid

36. 33
Quality of Care: discharges for
ambulatory care
53 53 69 74 52 County Health
Rankings
% Diabetic Medicare enrollees
receiving HbA1c test
90% 88% 88% 83% 89% County Health
Rankings
% Chronically ill Medicare
enrollees admitted to hospice
in last 60 mos. of life
Socioeconomic Factors
Education: % high school
students graduating in 4-yrs
85% 90% 85% 77% 92% County Health
Rankings
% Population age 25+ with 4-
year college degree or higher
Employment: % Population
age 16+ unemployed & looking
for work
17.6% 15.6% 15.3% 13.6% 5.3% County Health
Rankings
Income: % Children (<age 18)
living in poverty
24% 23% 25% 19% 11% County Health
Rankings
Gini coefficient of household
income inequality
Census/ACS
Family & Social Support: %
Adults reporting not getting
social/emotional support
18% 11% 18% 20% 14% BRFSS
% Households that are single-
parent households
28% 26% 27% 32% 20% County Health
Rankings
Physical Environment
Air Quality: # Days air quality
was unhealthy due to fine
particulate matter
1 1 1 5 0 EPA/CDC
# Days that air quality was
unhealthy due to ozone
1 3 1 3 0 EPA/CDC
Built Environment
% Zip Code in county with
healthy food outlet
33% 75% 86% 73% 92% County Health
Rankings
Liquor stores/10,000 pop. 13.0 1 1 14.0 County Health
Rankings
Appendix 2
Exhibit 4: CDC County Health Ranking Data Grid

37. 34
Community Support Survey
Thank you for your assistance on
this survey. It is OK to skip any
question(s) you choose not to
answer.
Please tell us if you or members of
your household use these
community services and find them
of help and value.
Place a check mark in the box or
boxes for your answers. Either pen
or pencil is OK. To change an
answer, please erase completely.
1. Which, if any, of these services are used
by a member of your household? (Check all
that apply)
DHS Food Assistance ........................ 
DHS Income Assistance..................... 
Free or Reduced School Meals............ 
Medicaid.......................................... 
Subsidized Child Care ....................... 
Free Community Health Clinic/Med Access
Program .......................................... 
Tencon............................................ 
Health Dept. Programs (WIC, Family
Planning, Immunizations ................... 
Subsidized Housing........................... 
MI Works......................................... 
Head Start/Early Head Start .............. 
New Hope Shelter............................. 
Family Resource Center/OASIS .......... 
Dental Clinics North .......................... 
Community Meals/Local Food Banks ... 
Salvation Army ................................ 
Friends Ministry................................ 
NW MI Community Action Agency....... 
Love INC. ....................................... 
MSU Extension ................................. 
Northern Lakes Community Mental
Health............................................. 
Council on Aging .............................. 
Catholic Human Service Programs ...... 
Other
2. What kinds of community services have
been very helpful to you? Help with (check
all that apply)
Clothing ...........................................
Job training or education....................
Job searching ...................................
Keeping a job ...................................
Reading and writing English................
Housing ...........................................
Food assistance ................................
Transportation ..................................
Child care.........................................
Medical care .....................................
Dental care.......................................
Alcohol or drug treatment ..................
Counseling on relationships with spouse,
partner, family or others ....................
I have not needed or been helped by any
of these ...........................................
Any other helpful community service
3. What kind of additional help do you
need, that no program is now providing to
you? Help with… (Check all that apply)
Clothing/laundry ...............................
Job training or education....................
Job searching ...................................
Keeping a job ...................................
Reading and writing English................
Housing ...........................................
Food assistance ................................
Transportation ..................................
Child care.........................................
Medical care .....................................
Dental care.......................................
Alcohol or drug treatment ..................
Counseling on relationships with spouse,
partner, family or others ....................
Optical (vision) service.......................
Nothing special .................................
Something else
Appendix 3

38. 35
4. Is there someone outside of your
household you can turn to for help?
Yes ................................................. 
No .................................................. 
If Yes, who is that person?
Friend ............................................. 
Family member ................................ 
Minister/pastor/priest........................ 
Community services ......................... 
Other
5. Which county do you live in?
Wexford .......................................... 
Missaukee ....................................... 
Osceola........................................... 
Other
6. How long have you been living in the
Wexford/Missaukee area?
Less than 3 months .......................... 
Between 3 months and a year............ 
Between 1 and 3 years...................... 
Between 3 and ten years................... 
Longer than 10 years........................ 
7. What is your present age?
25 years or less................................ 
26-35 years..................................... 
36-45 years..................................... 
46-55 years..................................... 
56-65 years..................................... 
Over 65 years .................................. 
8. Are you male or female?
Male ............................................... 
Female............................................ 
9. Are you currently….
Married ........................................... 
Separated but married ...................... 
Divorced ......................................... 
Widowed ......................................... 
Singled, never married...................... 
A member of an unmarried couple...... 
10. How do you describe your race or
origin?
White and not Hispanic ..................... 
Hispanic white.................................. 
Hispanic other.................................. 
Black or African American.................. 
Asian or Pacific Islander .................... 
American Indian or Alaskan native...... 
Other racial group or origin................ 
Mixed race....................................... 
11. What is the highest grade or year of
school that you have completed?
4th
grade or less................................
8th
grade or less................................
Less than high school graduation ........
High school diploma or GED................
High school or GED & job-training .......
Some college....................................
2 Year college degree or certificate......
4 Year college degree or more ............
12. What would you estimate as the yearly
income from your household from all
sources, before taxes?
Less than $5,000 ..............................
$5,000-$9,999..................................
$10,000-14,999................................
$15,000-$19,999 ..............................
$20,000-$24,999 ..............................
$25,000-$29,999 ..............................
$30,000-$39,999 ..............................
More than $40,000............................
13. How many people are supported at
least in part by the household income,
counting yourself?
1 2 3 4 5 6 7 8+
Number of people        
14. How many people in the household are
children 18 years old or Younger?
1 2 3 4 5 6 7 8+
Number of children        
15. When thinking about the future, what
is your best hope for improving your life?
Getting more education......................
Finding a partner who will help out ......
Getting healthy .................................
Finding a job that will support my
Family .............................................
Kicking my bad habits........................
Finding affordable housing..................
I‘m happy with my life now ................
Other
Appendix 3

39. 36
16. What barriers prevent you from
improving your life? (check all that apply)
Child /child care issues...................... 
Transportation issues........................ 
Budgeting/money management.......... 
Alcohol/drug abuse........................... 
Poor reading/writing skills ................. 
Health/mental health problems .......... 
Other
17. Would you say that in general your
physical health is
Excellent ......................................... 
Very good........................................ 
Good .............................................. 
Fair................................................. 
Poor................................................ 
18. Would you say that in general your
Mental Health (things like stress,
depression, and problems with emotions) is
Excellent ......................................... 
Very good........................................ 
Good .............................................. 
Fair................................................. 
Poor................................................ 
19. How much do you feel that people in
your community accept you and are willing
to help you?
Very much....................................... 
Quite a lot ....................................... 
A little bit ........................................ 
Not at all ......................................... 
I don’t know .................................... 
20. When you think about the life you live,
how satisfied are you?
Completely satisfied.......................... 
Mostly satisfied ................................ 
Not satisfied, but getting there........... 
Mostly not satisfied........................... 
Not satisfied at all ............................ 
21. What skills or talents do you have that
could help others?
Cooking ...........................................
Sewing ............................................
Child care.........................................
Carpentry.........................................
Welding ...........................................
Auto repair.......................................
Other
22. Which best describes you?
Employed full-time ............................
Employed part-time by choice.............
Employed part-time but want to work more
hours...............................................
Self-employed ..................................
Not employed because I am a
Homemaker......................................
Not employed because I am a student .
Not employed because I am a
caregiver..........................................
Not employed because I am unable to
work................................................
Not employed because I am retired .....
Retired, but working to supplement
income.............................................
Out of work for less than one year ......
Out of work for more than one year.....
23. Do you have any trouble keeping a
job?
Yes..................................................
No...................................................
If YES, please tell us what makes it hard to
keep a job? (check all that apply)
Transportation issues.........................
Child care issues ...............................
Children’s special needs .....................
Getting along with boss/co-workers.....
Disability..........................................
Health problems................................
Poor reading and writing skills ............
Lack of education or skills ..................
Housing issues..................................
Substance abuse issues .....................
Adult care-giver issues.......................
Health/mental health issues ...............
Something else
Appendix 3

40. 37
24. When you need to get to places too far
to walk, what way do you use most often?
My own car...................................... 
A relative’s vehicle............................ 
Someone else’s car........................... 
Motorcycle....................................... 
CWTA or other public transportation ... 
Taxi ................................................ 
Bicycle ............................................ 
Hitch hiking ..................................... 
Another way
25. Which best describes the place where
you live?
House ............................................. 
Apartment ....................................... 
Mobile Home.................................... 
With friends or family, but not place of
my own........................................... 
Community shelter ........................... 
Tent................................................ 
Car, truck, van, RV or boat ................ 
On the street ................................... 
26. If you do live in a house, apartment,
or mobile home, is it
Owned by you or another household
member with a mortgage or a loan......
Owned free and clear by you or another
household member............................
Rented.............................................
Occupied without a rent payment........
AND IN CLOSING….
Is there anything else you would like to tell the community about how to better reach and serve
our friends, neighbors, and families?
Thank you for your time!
Please place the completed survey in the collection box.
Appendix 3

41. 38
YOUTH NEEDS SURVEY
Youth Advisory Committee (YAC)
Part 1 –Important Issues facing youth today
Please check () the 5 most important issues you think are facing youth today.
_____Alcohol and drug abuse _____Teen sexual activity or pressure
_____Smoking/Use of tobacco products _____Stress/School pressure
_____Lack of activities outside school _____Cliques
_____Family problems (divorce, abuse, _____ Bullying (personal threats, gossiping
finances, etc) internet harassment, etc.)
_____Sexual Assault (rape, date rape, _____Discrimination (race, gender, sexuality,
sexual harassment) appearance, religious, etc.)
_____Health issues (eating disorders/obesity/ _____Personal Safety (gangs, fights, school
anorexia/bulimia) violence, threats, etc.)
_____Depression/Suicide/Loss _____Self-esteem/Respect for yourself & others
_____Teen Crime (shoplifting, vandalism, etc.) _____Other (please specify)________________
Part 2—Needed programs for Youth
The Youth Advisory Committee (YAC) provides money to support youth programs and
activities. Which program areas do you think the YAC should fund? Check() your top 5.
______Leadership activities _______Tutoring programs
______Counseling services _______After school recreation/Social activities
______Transportation services _______Volunteer programs (finding opportunities)
______Mentoring programs _______Community youth organizations (4-H, Scouts,
S.A.D.D., church, etc.)
______Job development and opportunities (resumé building, interview skills)
______Personal development programs (art, music, fitness, theater, literacy, etc.)
______Information about educational opportunities after high school
______Other (please specify) ______________________________________________________
Appendix 4

42. 39
PART 3—Use of Leisure Time
What do you do during your free time? Check all that apply.
______Work ______Sports _______Study/Read
______Church Activities ______Family Activities _______Spend time with friends
______Volunteer ______Music, Art, Dance _______Exercise
______Clubs (4-H, Scouts, BPA, SADD, etc.) _______Computer/TV/Video games
______Academic Clubs (Quiz Bowl, Foreign Language Clubs, Student Council, etc.)
______Other: _______________________________________________
What limits you from participating in after-school or weekend activities?
Check all that apply.
______not enough time _______family ______not interested
______work obligations _______transportation ______money/finances
______don’t know what is going on
_______other:_________________________________
How much leisure time do you have? _______some each day
_______weekends
_______none
Part 4--Please tell us about yourself: (No names)
School: _______________________________________
Grade: _____________ Age: ___________
Gender: ______ Male ______ Female
I live: _______within the city/town limits _______outside of town (in the country)
Appendix 4

43. 40
2009-10 MiPHY Results
Wexford/Missaukee Students
Wexford Missaukee
2009
YRBS
Percentage of students who ever drank alcohol
7th 19.7 20.3 n/a
9th 40.3 56.3
68.8
11th 56.8 71
Percentage of students who drank alcohol during
the past 30 days
7th 11.1 7.3 n/a
9th 14.4 25.2
37
11th 32.2 35.7
Percentage of students who have ever been drunk
7th 12.2 8.8 n/a
9th 22 39
n/a
11th 45.2 52
Percentage of students who ever rode in a car driven
by someone who had been drinking alcohol
7th 33.7 35.7 n/a
Percentage of students who rode in a car or other
vehicle driven by someone who had been drinking
alcohol one or more times during the past 30 days
9th 20.3 28.8
27.5
11th 19.5 30.8
Percentage of students who drove a car or other
vehicle when they had been drinking alcohol one or
more times during the past 30 days
9th 4 5.5
8.4
11th 9.3 14
Percentage of students who reported sort of easy or
very easy to get cigarettes
7th 40.9 36.2 n/a
9th 60.7 77.5
n/a
11th 79.2 80.6
Percentage of students who ever smoked a whole
cigarette
7th 11.6 9.3 n/a
9th 25.1 36.7
46
11th 33.2 39.1
Percentage of students who smoked cigarettes on
one or more of the past 30 days
7th 10.5 4.2 n/a
9th 12.6 18.1
18.8
11th 16.7 20.2
Among students who are current smokers, the
percentage who tried to quit smoking during the
past 12 months
9th 73.7 63
53.6
11th 58.7 57.7
Percentage of students who ever tried marijuana
7th 7.6 5.1 n/a
9th 19.2 28.9
36.5
11th 35.3 37.5
Percentage of students who used marijuana during
the past 30 days
7th 7.2 2.8 n/a
9th 8.5 18.9
20.7
11th 16.6 13.5
Percentage of students who were offered, sold, or
given an illegal drug on school property by someone
during the past 12 months
7th 10.2 8.4 n/a
9th 19.7 28.4
29.5
11th 16.5 19.3
Percentage of students who ever seriously
considered attempting suicide
7th 22.9 39.2 n/a
Appendix 5
MiPHY – Wexford/Missaukee Counties

44. 41
Percentage of students who ever made a plan about
how they would attempt suicide
7th 17.8 25.7 n/a
Percentage of students who ever tried to kill
themselves
7th 7.1 14.9 n/a
Percentage of students who felt so sad or hopeless
almost every day for two weeks or more in a row
that they stopped doing some usual activities during
the past 12 months
9th 41.1 32.9
27.4
11th 31.5 36.1
Percentage of students who seriously considered
attempting suicide during the past 12 months
9th 27.1 22.4
16
11th 17.6 22
Percentage of students who made a plan about how
they would attempt suicide during the past 12
months
9th 22.4 11.8
14.6
11th 14.9 20.9
Percentage of students who actually attempted
suicide during the past 12 months
9th 16.3 12.2
9.3
11th 4.2 11.3
Percentage of students who ever had sexual
intercourse
7th 5.8 6.5 n/a
9th 19.7 35.9 45.6
11th 48.5 56.9
Percentage of students who had sexual intercourse
with four or more people during their life
9th 3.1 9.1
13.6
11th 8.1 19.5
Percentage of students who had sexual intercourse
during the past 3 months
9th 15 25.9
34.1
11th 35.4 42.6
Among students who had sexual intercourse during
the past three months, the percentage who drank
alcohol or used drugs before last sexual intercourse
9th 20.7 20
24.7
11th 20.7 20.4
Among students who had sexual intercourse during
the past three months, the percentage who used a
condom before last sexual intercourse
9th 69 63.9
61.4
11th 46.6 61.8
Among students who had sexual intercourse during
the past three months, the percentage who used
birth control pills to prevent pregnancy before last
sexual intercourse
9th 14.3 11.1
21.4
11th 22.4 37
Percentage of students who had ever been pregnant
or gotten someone else pregnant
9th 1 4.9
6.2
11th 6.1 8.6
Percentage of students who have ever been
physically forced to have sexual intercourse when
they did not want to
9th 5 6.1
10.4
11th 6.1 10.5
Of students who ever had sexual intercourse, the
percentage whose first partner was 3 or more years
older
9th 28.2 23.5
18.7
11th 25.6 24.3
Appendix 5
MiPHY – Wexford/Missaukee Counties

45. 42
Percentage of students who saw a doctor or
healthcare provider for a check-up or physical exam
when they were not sick or injured during the past
12 months
9th 61.4 64.1
61.8
11th 66.8 68.1
Percentage of students who had ever been told by a
doctor or nurse that they had asthma
9th 18.1 21.3
23.2
11th 23.5 22.6
Percentage of students who had been told by a
doctor or nurse that they had asthma and still have
asthma
9th 11.9 11
11.6
11th 12.8 13.1
Percentage of students who ate five or more
servings per day of fruits and vegetables during the
past seven days
9th 35 41.2
19.6
11th 26.5 32.1
Percentage of students who drank three or more
glasses per day of milk during the past seven days
7th 32.7 29.6 n/a
9th 27.7 28.9
13.3
11th 19.4 28.9
Percentage of students who had breakfast every day
in the past week
7th 56.5 51.7 n/a
9th 42.7 44.1
n/a
11th 40 38.7
Percentage of students who are obese (at or above
the 95th percentile for BMI by age and sex)
7th 15.6 22.4 n/a
9th 18 17.3
11.9
11th 15.9 20.6
Percentage of students who are overweight (at or
above the 85th percentile and below the 95th
percentile for BMI by age and sex)
7th 19.1 19.4 n/a
9th 19.6 14.7
14.2
11th 15.6 19.8
Percentage of students who were trying to lose
weight
7th 43.1 52.1 n/a
9th 50.3 44.1
44.8
11th 43.5 45.1
Percentage of students who were physically active
for a total of at least 60 minutes per day on five or
more of the past seven days
7th 67.3 63.6 n/a
9th 61.5 64
46.8
11th 56.6 55.3
Percentage of students who watched three or more
hours per day of TV on an average school day
7th 29.9 27.8 n/a
9th 26.5 32.9
29.6
11th 25.7 29.5
Percentage of students who played video or
computer games or use a computer for something
that is not school work three or more hours per day
on an average school day
7th 23.4 18.8 n/a
9th 21.2 16.9
n/a11th 16.2 13.7
Appendix 5
MiPHY – Wexford/Missaukee Counties

46. 43
Priority #1
Indicator Leading
cause of
death?
Identified
priority in
community
input
Within
MO’s
capacity to
impact
Area Rate Healthy People
2010 benchmark
Compared to state
average
Compared to
national average
Selection as CAN
key indicator?
Diabetes
(death rate)
No Yes Moderate 20.4 /100,000 46
Below
24.3
Below
21.8
Below
Yes
(MDCH Vital Stats)
Cardiovascular disease
(death rate)
Yes Yes Moderate Wex. 172.6
Miss. 249.0/100,000
162
Above
169
Above
144
Above
Yes
(MDCH Vital Stats)
Cancer
(overall death rate)
Yes Yes Moderate Wex 168.9
Miss 182.4
158.6
Above
187.3
Below
178.4
Below
Yes
(MDCH Vital Stats)
COPD
(death rate)
Yes No Moderate Wex 57.0
Miss. 43.4
62.3
Below
45.1 (2009)
Wex. Above
40.6 (2008)
Wex. Above
Yes
(MDCH Vital Stats)
Miss. Below Miss. Below
Obesity No Yes Moderate Wex. 31%
Miss. 32%
15%
Above
31%
Above
25%
Above
Yes
(County Health
Rankings)
Teen pregnancy
(teen birth rate)
No Yes Low Wex. 53/1000 43/1000
Above
35 Wex
Above
22 Wex
Above
No
(County Health
Rankings)
Miss. 38 Miss. Below Miss. Below Miss. Below
Tobacco use
(adults smoking)
Yes Yes Moderate 27% 12%
Above
22%
Above
15%
Above
Yes
(County Health
Rankings)
Appendix 6
Priority 1, Priority2, Health Indicators Grid

47. 44
Indicator Leading
cause of
death?
Identified
priority in
community
input
Within
MO’s
capacity to
impact
Area Rate Healthy People
2010 benchmark
Compared to state
average
Compared to
national average
Selection as CAN key
indicator?
Alcohol use
(binge drinking)
No Yes Moderate 16% Wex. 13.4% 19%
Below
15.5%
Wex. Above
Yes
(County Health Rankings)
8% Miss. Miss. Below Miss. Below
Immunizations No No Low Wex 76.6%
Miss. 73.2%
80%
Below
76.5%
Below
70.5%
Above
No
(KidsCount Databook)
Oral health No Yes Low Wex 30.6%
Miss. 38.3%
(no dental)
56% annual dental
visits
N/A N/A No
(BRFS)
Low birth weight Yes Yes Low 6.7% 5%
Above
8.2%
Above
6.0%
Above
No
(CHR)
STDs
(Chlamydia per
100,000 pop.)
No No Low Wex 158
Miss. 120
N/A 446
Below
83
Above
No
(CHR)
HIV
(death rate)
No No Low 0 0.7/100,000
Below
1.8/100,000
Below
3.7/100,000
Below
No
(MDCH)
Injury
(Unintentional
injury deaths)
No No Low 14.7/100,000 17.1
Below
35.4
Below
38.6
Below
No
(MDCH)
Substance abuse
(total treatment
admissions)
No Yes Moderate Wex 458
Miss. 93
N/A 3rd highest N/A Yes
(NMSAS) 30 county region
3rd lowest
Priority #2
Appendix 6
Priority 1, Priority2, Health Indicators Grid