Executive Summary

AppHealthCare, in collaboration with various agencies and community partners, has released the Community Health Report for Ashe County. This report identifies public health priorities and provides a foundation for work that will take place in the following years.

The Community Health Report is published every three years in partnership with Appalachian District Board of Health, AppHealthCare, and many other partnerships, individuals, and agencies. The Community Health Report follows an assessment process involving the community to identify and analyze community health needs and assets, prioritize those needs and then implement a plan to address significant unmet needs.

The Community Health Report provides results from a community input opinion survey and review of community data which includes income, poverty, employment, community safety, housing, behavioral health, and more. The information is used to guide the work of local health departments and community partnerships to address community concerns and monitor progress toward projected goals.

What Can We Do Together to Improve Our Community’s Health?

• Practice safe prescription medication use by taking correctly, storing securely, disposing properly, and never sharing.
• Health begins where we live, learn, work and play. Take action in building our neighborhood to be safe and healthy.
• Being healthy takes a community. Attend a Mental Health First Aid training and join local community groups that work to support mental health systems.
• Your opportunity for health starts long before you need medical care. Sign up for your local Women, Infant & Children (WIC) program through AppHealthCare.
• The opportunity for health begins in our families, neighborhoods, schools, and jobs. Participate in local bike and walk safety programs to and from school. Being healthy takes a community.
• Your neighborhood or job shouldn’t be hazardous to your health. Support tobacco-free living.
• Health starts—long before illness—in our homes, schools, and jobs. Investing in our mothers and children is investing in our future.
• Live active, eat local vegetables and fruits.
• All citizens have the opportunity to make the choices that allow them to live a long, healthy life. Support local policies for sidewalks and bike lanes.

Priorities

The health priorities below highlight key areas that community coalitions within Ashe County will focus on and work to improve from 2020-2023:

• Mental/Behavioral Health
• Substance Use & Misuse
• Housing*

This report completes the first phase in the Community Health Assessment process. The second phase is taking place now through the development of Community Health Improvement Plans that will guide work to the health priorities in Ashe County.

Together, we will work toward a shared goal for a healthier Ashe County.

To view the Community Health Report for Ashe County, visit AppHealthCare’s website.

For additional information about AppHealthCare or other community resources and health-related data, please call our offices, Alleghany (336) 372-5641, Ashe (336) 246-9449, Watauga (828) 264-4995. For more information, visit our website at www.AppHealthCare.com and follow us on Twitter and Facebook.

*Housing was selected as a priority but due to lack of momentum we have not moved forward with activities on this topic. Conversations continue with community partners about how AppHealthCare can be involved.

Why Is This Important?

One in five adults (18.77 percent) in North Carolina has a mental health condition. More than half of adults in North Carolina (54.6 percent) with any mental illness report not receiving mental health treatment or counseling of any kind. One out of every three adults in North Carolina with mental illness are uninsured (Mental Health America 2020 Adult Data). People with mental and substance misuse disorders may die decades earlier than those without mental health or substance use disorders. This is mostly due to untreated and preventable chronic illnesses like hypertension, diabetes, obesity, and cardiovascular disease. Poor health habits such as lack of physical activity, poor nutrition, smoking, and substance misuse can worsen these chronic diseases.

What We Do

The Farmworker Health Program (FHP) at AppHealthCare strives to improve the health of farmworkers. Farm work is a dangerous occupation as workers face threats to their physical and mental health. Farmworkers most times lack medical coverage, and face language and transportation barriers.

Who We Serve

Seasonal and migrant farmworkers in Ashe and Alleghany Counties.

How We Impact

The Farmworker Health Program has been working on providing access to behavioral health services to farmworkers in Ashe and Alleghany Counties, and hopes to be able to provide a limited number of services internally in the coming months. Additionally, we seek to better bridge Peer Support services and Behavioral Services so that individuals with substance-use disorder can have access to mental health support.

What We Do

AppHealthCare has onboarded contractors to work with local organizations to establish policies and/or programs to address suicide prevention. Additionally, contractors will work with organizations and community members to provide gatekeeper training for suicide prevention. Types of training will be determined with the input of community members.

Who We Serve

AppHealthCare hopes to train individuals in a variety of settings to ensure common language and awareness exist across communities.

How We Impact

The goal of this effort is to empower community members to respond in situations where someone may be at risk for suicide.

Status of Program for SOTCH Report

Two contractors have received train-the-trainer (T4T) for QPR, safeTALK, AMHFA, CALM and are about to attend the ASIST T4T after being selected through a competitive application process through the state. Two trainings were successfully held upon completion of T4T, with two additional trainings scheduled at the beginning of 2024.

Why Is This Important?

As in other states, North Carolina has experienced a sharp increase in the number of drug overdose deaths over the last decade, largely due to the opioid epidemic. Substance Use Disorder has devastating impacts on the life of the people who experience it, their families, and their communities.

Substance use disorders (SUDs) are chronic or recurrent conditions that, like other chronic illnesses, require ongoing care and treatment for individuals to regain health and maintain recovery. As with any chronic disease, prevention, identification, treatment, and recovery services and supports are essential to ensuring positive health outcomes. Effective treatments for SUDs and underlying mental and physical health problems exist; however, access to services and supports for SUDs varies greatly across the state.

Having a SUD affects an individual’s relationships with family and friends, ability to attend school or work, their overall physical and mental health, and may lead to problems with the legal system. In addition to increases in drug overdoses, the opioid epidemic has had devastating consequences including the spread of HIV and hepatitis B and C and increased rates of child maltreatment and entry into foster care as more and more parents and other relatives develop and struggle with SUDs.

Tobacco use remains the leading preventable cause of early death and disease in North Carolina and the nation. Tobacco use and secondhand smoke exposure are responsible for multiple causes of preventable morbidity and mortality in North Carolina. While combustible cigarette use has decreased among North Carolina’s youth, prevalence among adults has declined only slightly, and there are major disparities of tobacco-attributable disease and death among population groups. E-cigarette use among young people has become epidemic in North Carolina and the nation and poses a public health threat.  

Also, excessive drinking, a major cause of morbidity and mortality across the United States, has significant impacts on individuals, families, communities, and state and local economies. Alcohol is the third leading cause of preventable deaths in North Carolina.   

What We Do

Appalachian District Health Department's Peer Support Program will maintain or expand one or more syringe services programs (SSPs) through a host organization, Olive Branch Ministries, that has experience working with people directly impacted by drug use. Syringe services programs (SSPs) are community-based prevention programs that can provide a range of services, including linkage to substance use disorder treatment; access to and disposal of sterile syringes and injection equipment; and vaccination, testing, and linkage to care and treatment for infectious diseases. The PSS Program will also continue to work with justice-involved individuals and their family members, conduct Narcan and harm reduction trainings, and advocate for more harm reduction, recovery and prevention services. 

Source: CDC

Who We Serve

Any person who uses drugs and their family members, or newly in or seeking recovery. 

How We Impact

SSPs protect the public and first responders by facilitating the safe disposal of used needles and syringes. Providing testing, counseling, and sterile injection supplies also helps prevent outbreaks of other diseases. Nearly thirty years of research shows that comprehensive SSPs are safe, effective, and cost-saving, do not increase illegal drug use or crime, and play an important role in reducing the transmission of viral hepatitis, HIV and other infections.

Source: CDC

Status of Program for SOTCH Report

Through the Vital Strategies opioid settlement matching grant, AppHealthCare has been able to sustain the essential work of the peer support program, as well as the Post Overdose Response Team (PORT). While PORT is not without it's challenges, we are grateful for opportunities to continue to collaborate with Ashe Medics Community Paramedic Program and Ashe Memorial Hospital to provide direct service to community members who have experienced an overdose.

Progress on CHIPs

Public Health Priorities

The Ashe Health Alliance and Community Health Assessment workgroup members selected the public health priorities in July 2021. These priorities were chosen based on the 2020 Ashe County Community Health Assessment. The public health priorities identified for Ashe County include mental and behavioral health, substance use and misuse prevention, and housing. Due to lack of momentum we have not moved forward with activities on housing. Conversations continue with community partners about how AppHealthCare can be involved.

Health Priority: Mental and Behavioral Health

Update to Local Community Objectives

Integrated Behavioral Health

Behavioral health describes the connection between behaviors and the wellbeing of the body, mind, and spirit. Behavioral health includes not only our mental health, but how our behaviors—such as eating habits or use of alcohol—impact our wellbeing. The number of adults with a serious mental illness in the U.S. has increased from 4.6 percent from 2017-2018 to 5.6 percent from 2019-2020. With the increase in mental illness, AppHealthCare’s Health Clinic in Ashe County continues to improve access to counseling, referral services, case management, and crisis management. One way this has been accomplished is by establishing a full time onsite Behavioral Health Consultant to provide integrated behavioral health.  

Seeking primary healthcare is often the first step to accessing behavioral healthcare. Primary care providers are now moving toward a system of integrated care where both general and behavioral healthcare are provided. Integrating mental health and primary care services have been shown to produce the best outcomes for people with multiple healthcare needs. People with mental health and substance misuse disorders may die decades earlier than those without mental health or substance use disorders. This is mostly due to untreated and preventable chronic illnesses like hypertension, diabetes, obesity, and cardiovascular disease. Poor health habits such as lack of physical activity, poor nutrition, smoking, and substance misuse can worsen these chronic diseases. Trauma can also increase the risk of developing substance misuse, and substance misuse increases the likelihood that individuals will experience trauma. Building resilience in a community is a key strategy for addressing trauma and substance use. 

Farmworker Health Program and Behavioral Health

The Farmworker Health Program (FHP) at AppHealthCare strives to improve the health of seasonal and migrant farmworkers in Ashe and Alleghany Counties. Farm work is a dangerous occupation as workers face threats to their physical and mental health. Farmworkers most times lack medical coverage, and face language and transportation barriers. Through the FHP, AppHealthCare works to address these barriers by providing translation and transportation services, as well as access and financial assistance for medical, dental, and behavioral health needs. 

The Farmworker Health Program has been working on providing access to behavioral health services to farmworkers in Ashe and Alleghany Counties, and hopes to be able to provide a limited number of services internally in the coming months. Conversations continue around capacity of the behavioral health team to assist in providing services to both farmworkers and individuals with substance use disorders. Once a referral network is successfully established, we will track referrals served by the behavioral health team.

School Based Behavioral Health 

AppHealthCare works with the Ashe School Health Advisory Council (SHAC) around student health, including disseminating the Youth Risk Behavior Survey (YRBS). YRBS results are provided to the SHAC team to help influence resources provided to students. AppHealthCare's School Based Health Center reaches all middle school students in Ashe County and has an on-site Behavioral Health Clinician to work with youth. The Assessment, Support, & Counseling (ASC) Center is a valuable program that supports Ashe County School students in mental and behavioral health. As the school mental health program, the ASC Center works closely with schools and local partners to prevent suicide. According to the 2019 North Carolina Youth Risk Behavior Survey, 36.3% of high school students reported that they felt sad or hopeless for two weeks or more in a row during the past 12 months, 18.9% of high school students considered attempting suicide, 15.4% of high school students and 16.3% of middle school students made a suicide plan, and 9.7% of high school students and 11.5% of middle school students attempted suicide. The following table outlines this data, collected in 2021, locally in Ashe County. More information through the NC Institute of Medicine about Youth Suicide & Suicide Attempts Rising in U.S. and N.C. can be found here. 

Distribution of Resource Cards

Ashe Health Alliance has a subgroup focused on Mental and Behavioral Health. This subgroup understands that high doses of early adversity significantly increase an individual’s risk of suicide later in life. This subgroup has discussed working with the School Health Advisory Council (SHAC) to distribute a Survive and Thrive resource card to ensure that Ashe County's youngest citizens are aware of mental health services that are available to them. These cards would outline signs of serious distress, helpful tips for reducing stress, and a list of local and national crisis resources.

Ashe Youth Task Force

The Ashe Youth Task Force is a group led by Western Youth Network that collaborates with organizations in the area to provide educational resources and promote programming that corresponds with different problem areas that youth face. Lately, mental health has been the main topic of these meetings. The members all have agreed to work with the Systems of Care grant through Vaya and will focus on family/youth engagement and trauma/resilience. Additionally, task force members and Ashe County School staff have been partnering to develop calm corners in the schools to support behavioral regulation and resilience among students and faculty.

Mobile Crisis Management

Daymark Recovery Services offers Mobile Crisis Management services that provide a comprehensive crisis intervention in the least restrictive environment with a team perspective to meet any individual’s needs. The service operates year-round, seven days per week, twenty-four hours per day. 

National Alliance on Mental Illness

The National Alliance on Mental Illness (NAMI) is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. NAMI High Country, which includes Ashe County representation, wants to make the High Country a safer space for those experiencing mental illness by ending the stigma associated with it. NAMI High Country wants to ensure that those who need help have access to affordable care and support. NAMI High Country is here to facilitate recovery and resiliency for families and individuals and ultimately empower those who join us to be able to serve their community.

Health Priority: Substance Use and Misuse Prevention

Update to Local Community Objectives

North Carolina Opioid Action Plan

AppHealthCare has committed to the incorporation of the North Carolina Opioid Action Plan, evidence-based opioid and substance use prevention strategies, harm reduction tactics and methods, including safer syringe and naloxone distribution programs. These efforts are directly aligned with our mission and values to ensure the continuation of support for the identified Health Priority of Substance Use and Misuse Prevention determined through the Community Health Assessment and reviewed by coalitions within Ashe County. The NC Opioid Action Plan Objectives align with Ashe County’s. These include the following: 

Prevention

• Cutting supply of inappropriate prescriptions and illicit opioids
• Supporting youth through targeted programs to reduce youth misuse of the drugs
• Improving maternal and prenatal care for women battling substance abuse

Reducing Harm

• Making the naloxone kits more widely available to the most burdened communities

Connecting to Care

• Expanding access to treatment and recovery support
• Addressing the needs of justice-involved populations

A data dashboard developed by the NC Department of Health and Human Services helps to track and monitor the metrics in the Opioid Action Plan.

Peer Support Specialists

In 2019, AppHealthCare hired two part-time Peer Support Specialists (PSS). Then applied for the Community Linkages to Care grant that, once received, allowed for the support of an additional (full-time) PSS to serve the district. There are three PSS that work across the district. The PSSs work as advocates for those struggling with substance use disorder by relating on a personal level through lived experience to promote trust among the people they serve. The PSSs work to serve the community through education, prevention measures, harm reduction, training, connecting individuals to care, working with justice-involved individuals, and helping with environmental and policy change work.

Current PSS initiatives are being captured and evaluated using a combination of pre- and post-test comparisons and follow up with program participants and agencies, as well as maintenance of data logs. The following are measures that are in place and have been tracked since February 2019 (when the NC CPSS program started):

• Board of Health resolution to support comprehensive strategies to address the opioid epidemic
• Total number of individuals served by NC Peer Support Specialists (PSS) across Alleghany, Ashe, and Watauga Counties: 591
• Total syringes returned: 51,932 (33,294 of those in Ashe County)
• Total naloxone kits distributed: 3,504 (2040 in Ashe County)
• Number of unique justice-involved persons served: 281 (131 in Ashe County)
• Number of justice-involved people and their families or loved ones educated on harm reduction strategies before release, including (but not limited to) training on how to recognize an overdose, how to administer naloxone, and how to prevent an overdose: 130
• Number of justice-involved individuals reporting overdose reversals: 37
• Percent of justice-involved individuals who are given access to naloxone upon release: 100% are offered - approximately 30% receive kits
• Number of Narcan/Naloxone trainings in business and agencies: 13 (including ASU, community organizations, businesses, churches), 220 kits distributed to 184 participants
• Number of average contacts with each individual served: 11
• Number of individuals connected to medical, social services, emergency housing, transportation, food, treatment, behavioral health: 394

Post-Overdose Response Team

Community collaboration is a key component of this strategy and having resources like the Post Overdose Response Team (PORT) that has been formed and is up and running in Ashe County. This is due to a partnership with Ashe Medics Community Paramedic Program and Ashe Memorial Hospital providing direct service to community members who have experienced an opioid overdose. AppHealthCare’s PSS have responded to 60 PORT calls since the program began in November 2020, and other successes include:

• Number of naloxone kits distributed through PORT = 166
• Number of overdose reversals reported through PORT = 36

Medication-Assisted Treatment

AppHealthCare has a physician certified to provide Medication-Assisted Treatment (MAT) services to patients with a diagnosis of Opioid Use Disorder (OUD). Over the past two years, the Ashe clinic (of AppHealthCare) has developed and grown this program, working with AppHealthCare’s Peer Support Specialists. MAT is the use of medications in combination with counseling and behavioral therapies for the treatment of OUDs. This combination of therapies has shown to be effective in the treatment of OUD and can help some people to sustain recovery.

E-Cigarette and Vaping Awareness in Schools

Youth use of tobacco products—in any form, including electronic nicotine delivery systems (ENDS) like e-cigarettes—is unsafe. Such products contain nicotine, which is highly addictive and can harm the developing adolescent brain. Using nicotine in adolescence may also increase risk for future addiction to other drugs. AppHealthCare is working alongside Western Youth Network & the Regional Tobacco Prevention and Control Manager to initiate talks with Ashe County Schools to implement the CATCH My Breath curriculum as well as to install vape detectors in school restrooms and locker rooms to further deter the use of electronic nicotine devices. 

While the results of the YRBS reflect that the number of students who used a vape in the past 30 days has decreased, we are noticing an increased outreach by administrators that are looking for guidance around the increase in the amount of vaping use that they are currently witnessing in the schools.  We are aiming to support ways to prevent and promote cessation with Ashe County students. 

Medicaid Tobacco Free Policy

Starting December 1, 2022, North Carolina Standard and Tailored Prepaid Health Plans serving Medicaid and uninsured patients will require contracted medical, behavioral health, and some intellectual/developmental disabilities (IDD)/traumatic brain injury (TBI) organizations to provide a 100% tobacco-free campus. On September 7th, 2021, DHHS released a memo to providers advising them of the new tobacco-related policy requirements going into effect December 2022. Daymark Recovery has begun to implement their tobacco-free campus policy and is working to make tobacco cessation part of the standard of care.

Live Vape Free NC

A media campaign aimed to help push vaping cessation among youth launched in Spring 2022.  The campaign is called Live Vape Free and is a digital campaign that will target youth.  The ads will drive those who click on the ad to a webpage where they can sign up to start the cessation program.  This campaign runs in a ten county region.

CTTS Training

AppHealthCare staff continue to work with providers across the district to obtain Comprehensive Tobacco Treatment Training. There is also a newly trained faculty member at Ashe County Schools. This training through Duke-UNC aims to train health professionals to provide evidence-based treatment for tobacco use and dependence. The program provides an impactful education experience for a wide variety of professionals, including clinicians, nurses, pharmacists, social workers, public health policy-makers, and more.

Quitline

AppHealthCare staff is also able to offer Quitline services to clients by referring them through their online referral platform. QuitlineNC provides free cessation services to any North Carolina resident who needs help quitting commercial tobacco use, which includes all tobacco products offered for sale, not tobacco used for sacred and traditional ceremonies by many American Indian tribes and communities. Quit Coaching is available in different forms, which can be used separately or together, to help any tobacco user give up tobacco.

Morbidity and Mortality Changes Since Last CHA

Emerging Issues Since Last CHA

Food Access

Under our Healthy Communities strategy our goal is to increase the number of new community venues providing access to healthy foods and/or the number of existing community venues providing enhanced access to healthy foods. This includes new efforts for implementation as a result of COVID-19. Healthy foods are defined by the USDA as nutrient-dense foods across and within all food groups and are mentioned in the USDA’s Dietary Guidelines for Americans 2020-2025. 

Dr. Stroud at the AppHealthCare Dental Clinic is working with a community member on a community garden that produces fresh produce to distribute at a food pantry for WIC recipients and the Migrant Farmworker population. Stroud hopes to address the food insecurity she witnesses in some of her dental patients and local families. With the help of partnerships, resources, energy and patience, she operates the AppHealthCare Community Dental Garden, which in 2020 yielded 360 pounds of produce and gave 70 families access to healthy food.

MedSouth  

The SouthMed program is an opportunity that AppHealthCare received in 2021 to partner with Wake Area Health Education Center  that focuses on healthy eating with inspiration from the Mediterranean Diet. This is a nutrition based program with the primary outcome objectives of improving blood pressure and weight loss. While this program is based on the principles of the Mediterranean Diet, it has been adapted to be more accessible to the southern population.  Participants in Ashe County were given the opportunity to be part of this program that consisted of 4 sessions across 4 months, and could receive up to $120 if they completed all three surveys they were asked to complete.  

Family & Social Supports

Adverse Childhood Experiences

Many health disparities begin early in life with Adverse Childhood Experiences (ACEs). ACEs are potentially traumatic events that can have negative, lasting effects on health and well-being. These experiences range from physical, emotional, or sexual abuse to parental divorce or the imprisonment of a parent. Initiatives such as the Positive Parenting Program and other family interventions through the Partnership of Ashe and the Ashe County Schools are successful at addressing these challenges because they address the whole person in the context of our relationships and local environment. 

Family Based Intervention: Family Connects

Through a collaboration between AppHealthCare and the Children’s Council of Watauga County, Family Connects International Nurse Home Visiting Program has expanded into Ashe County to increase child well-being by helping connect families with newborns to community resources. Using the Family Support Matrix, home visiting nurses assess the well-being of the mother, father, and infant by asking questions regarding general health, infant care, safety, social and emotional support needs, and more. All families in Ashe County are eligible for one home visit by a registered nurse to all parents of newborns up to 12 weeks old born in the service area, up to two additional home visits from the nurse home visitor for families who need additional support, and referrals to resources and services as needed. Family Connects staff have been recruiting at Ashe Memorial Hospital since October of 2021 when staff resumed home visits. As of April 2022, we are seeing a significant increase in post visit referrals completed, meaning that families are being connected successfully to the resources they need.

Family Based Intervention: Positive Parenting Program

Ashe County practitioners continue to implement positive parenting strategies in hopes of reducing serious negative childhood outcomes. Healthy children equal healthy adults later in life. How do we know that the Positive Parenting Program is working locally? The program is showing high approval scores from families. Improved child behavior and decreased parent stress is being reported based on Client Satisfaction Questionnaires received. The Triple P Team is working with partners and practitioners to consistently collect this data to ensure that important feedback loop is sustained.

New/Paused/Discontinued Initiatives Since Last CHA

Drug Users Health Program

In 2019, AppHealthCare’s Recovery Peer Support Specialists started collaborating and volunteering with Olive Branch Ministry to provide harm reduction resources and services to Ashe County residents and businesses. These resources and services include increased availability of Narcan/Naloxone and training, and safer supplies for drug users. AppHealthCare also collaborates with Olive Branch Ministry to receive TA and fulfill requirements of the Community Linkages to Care grant, which is a grant to help to increase access to care and working with justice-involved individuals. 

Advancing Equity Initiative

In 2021, AppHealthCare received a new opportunity to focus efforts on health equity for Historically Marginalized Populations (or HMPs). Under this initiative, AppHealthcare staff have reconvened the Equity Performance Improvement Team (or PIT) to guide internal efforts to improve agency policies and practices towards health equity, particularly regarding COVID-19 prevention and mitigation. The Advancing Equity initiative will also involve external efforts to engage community partners to collaboratively improve COVID-19 infection outcomes and as well as other long-term outcomes that disproportionately impact HMPs.

Progress on CHIPs

Health Priority: Mental and Behavioral Health

Update to Local Community Objectives

Gatekeeper Training

AppHealthCare recently realigned grant strategies to further focus resources toward mental health based on conversations with and feedback from community partners. AppHealthCare is in the process of onboarding contractors to work with local organizations to establish policies and/or programs to address suicide prevention. Additionally, contractors will work with organizations and community members to provide gatekeeper training for suicide prevention. Types of training will be determined with the input of community members. The goal of this effort is to empower individuals in a variety of settings to respond in situations where someone may be at risk for suicide. 

Farmworker Health Program and Behavioral Health

The Farmworker Health Program (FHP) at AppHealthCare strives to improve the health of seasonal and migrant farmworkers and their families in Ashe and Alleghany Counties. Farm work is a dangerous occupation as workers face threats to their physical and mental health. Farmworkers  face challenging conditions such as pesticide exposure, heat stress, lack of shade, long work hours and inadequate drinking water. Most farmworkers are under or uninsured and face language, transportation, and cultural barriers. Some have a fear of using healthcare services. Through the FHP, AppHealthCare works to build trustful relationships with farmworkers while helping overcome barriers by providing translation and transportation, as well as connecting to services such as dental, primary care, urgent care, and vision. The FHP continues to explore options for behavioral health and other specialty services. 

School Based Behavioral Health 

AppHealthCare works with the Ashe School Health Advisory Council (SHAC) around student health, including disseminating the Youth Risk Behavior Survey (YRBS). YRBS results are provided to the SHAC team to help influence resources provided to students. AppHealthCare's School Based Health Center reaches all middle school students in Ashe County and has an on-site Behavioral Health Clinician to work with youth. The Assessment, Support, & Counseling (ASC) Center is a valuable program that supports Ashe County School students in mental and behavioral health. As the school mental health program, the ASC Center works closely with schools and local partners to prevent suicide. According to the 2019 North Carolina Youth Risk Behavior Survey, 36.3% of high school students reported that they felt sad or hopeless for two weeks or more in a row during the past 12 months, 18.9% of high school students considered attempting suicide, 15.4% of high school students and 16.3% of middle school students made a suicide plan, and 9.7% of high school students and 11.5% of middle school students attempted suicide. The following table outlines this data, collected in 2021, locally in Ashe County. New data will be available in 2023. More information through the NC Institute of Medicine about Youth Suicide & Suicide Attempts Rising in U.S. and N.C. can be found here. 

Ashe SHAC continues to discuss ways to provide education on new and emerging substances, alcohol, vaping and more to parents, students and staff/faculty. Currently, law enforcement, health and wellness entities, DSS and other partners are working on awareness efforts related to Delta 8 THC, an emerging psychoactive cannabinoid.

Ashe Youth Task Force

The Ashe Youth Task Force is a group led by Western Youth Network that collaborates with organizations in the area to provide educational resources and promote programming that corresponds with different problem areas that youth face. Lately, mental health has been the main topic of these meetings. The members worked with the Systems of Care grant through Vaya to focus on family/youth engagement and trauma/resilience. Additionally, task force members and Ashe County School staff have collaborated to develop calm corners in the schools to support behavioral regulation and resilience among students and faculty. Other efforts include preparing and distributing resilience kits for students as well as getting feedback from students on the impact of the kits.

Health Priority: Substance Use and Misuse Prevention

Update to Local Community Objectives

Opioid Settlement

In July 2021, Attorney General Josh Stein announced a historic $26 billion agreement that will help bring desperately  needed resources to communities harmed by the opioid epidemic. The agreement resolves litigation over the role of  four companies in creating and fueling the opioid epidemic. A Memorandum of Agreement (MOA) between the State  and local governments directs how opioid settlement funds are distributed and used in our state. To maximize funds  flowing to North Carolina communities on the front lines of the opioid epidemic, the MOA allocates 15 percent of  settlement funds to the State and sends the remaining 85 percent to NC’s 100 counties and 17 municipalities.  

The overdose death rate in Ashe County was 7 out of 100,000 people in 2020. This represents 2 people in Ashe who died from overdose in that year. For every death, there are more non-fatal overdoses. While we are  not able to capture all opioid overdoses, emergency department visits for overdoses are one way to measure the number  of overdoses happening. The overdose emergency department visit rate in Ashe County was 99 out of 100,000 people in 2020. This represents 27 emergency department visits by Ashe residents for overdose in that year.

As a result of the opioid settlement, Ashe County government is set to receive $2,181,261 over an 18-year period. Before spending settlement funds, every local county or municipality must first select which opioid mitigation  strategies they would like to fund. 

In November 2022, Ashe County agencies and partners initiated a Results-Based Accountability (RBA) action planning process in which focus areas were determined for the next four years. In March 2023, the Ashe County Commissioners approved the utilization of $225,000 to fund two-year pilot projects based on Exhibit A strategies in the MOA. In alignment with guidelines set by the North Carolina Attorney General’s Office and North Carolina Department of  Health and Human Services, Ashe County will consider funding agencies to implement the following Exhibit A strategies: 

1. Collaborative strategic planning
2. Evidence-based addiction treatment
3. Recovery support services
4. Recovery housing support
5. Employment-related services
6. Early intervention
7. Naloxone distribution
8. Post-overdose response team
9. Syringe Service Program
10. Criminal justice diversion programs
11. Addiction treatment for incarcerated persons
12. Reentry programs

Priority will be given to projects that align with the top 5 focus areas determined through RBA action planning: 1) Connections to care, 2) Harm reduction, 3) Support for people in treatment and recovery, 4) Addressing needs of criminal-justice involved persons, and 5) Treatment of opioid use disorder.

In 2023, AppHealthCare in partnership with the County will release a Request for Proposals to fund eligible organizations to implement evidence-based, high-impact strategies to address the opioid epidemic in Ashe County, North Carolina. In addition, this RFP builds capacity and local  infrastructure to respond to the overdose crisis in Alleghany County, North Carolina. The goal of the RFP is to reduce overdose deaths, emergency department visits for overdose, and illicit opioid involvement.

Peer Support Specialists

In 2019, AppHealthCare hired two part-time Peer Support Specialists (PSS). Then applied for the Community Linkages to Care grant that, once received, allowed for the support of an additional (full-time) PSS to serve the district. There are three PSS that work across the district. The PSSs work as advocates for those struggling with substance use disorder by relating on a personal level through lived experience to promote trust among the people they serve. The PSSs work to serve the community through education, prevention measures, harm reduction, training, connecting individuals to care, working with justice-involved individuals, and helping with environmental and policy change work.

Current PSS initiatives are being captured and evaluated using a combination of pre- and post-test comparisons and follow up with program participants and agencies, as well as maintenance of data logs. The following are measures that are in place and have been tracked since February 2019 (when the NC CPSS program started):

• Board of Health resolution to support comprehensive strategies to address the opioid epidemic
• Total number of individuals served by NC Peer Support Specialists (PSS) across Alleghany, Ashe, and Watauga Counties: 591
• Total syringes returned: 51,932 (33,294 of those in Ashe County)
• Total naloxone kits distributed: 3,504 (2040 in Ashe County)
• Number of unique justice-involved persons served: 281 (131 in Ashe County)
• Number of justice-involved people and their families or loved ones educated on harm reduction strategies before release, including (but not limited to) training on how to recognize an overdose, how to administer naloxone, and how to prevent an overdose: 130
• Number of justice-involved individuals reporting overdose reversals: 37
• Percent of justice-involved individuals who are given access to naloxone upon release: 100% are offered - approximately 30% receive kits
• Number of Narcan/Naloxone trainings in business and agencies: 13 (including ASU, community organizations, businesses, churches), 220 kits distributed to 184 participants
• Number of average contacts with each individual served: 11
• Number of individuals connected to medical, social services, emergency housing, transportation, food, treatment, behavioral health: 394

Post-Overdose Response Team

Community collaboration is a key component of this strategy and having resources like the Post Overdose Response Team (PORT) that has been formed and is up and running in Ashe County. This is due to a partnership with Ashe Medics Community Paramedic Program and Ashe Memorial Hospital providing direct service to community members who have experienced an opioid overdose. AppHealthCare’s PSS have responded to 60 PORT calls since the program began in November 2020, and other successes include:

• Number of naloxone kits distributed through PORT = 141
• Number of overdose reversals reported through PORT = 42

Medication-Assisted Treatment

AppHealthCare has a physician certified to provide Medication-Assisted Treatment (MAT) services to patients with a diagnosis of Opioid Use Disorder (OUD). Over the past two years, the Ashe clinic (of AppHealthCare) has developed and grown this program, working with AppHealthCare’s Peer Support Specialists. MAT is the use of medications in combination with counseling and behavioral therapies for the treatment of OUDs. This combination of therapies has shown to be effective in the treatment of OUD and can help some people to sustain recovery.

E-Cigarette and Vaping Awareness in Schools

Youth use of tobacco products—in any form, including electronic nicotine delivery systems (ENDS) like e-cigarettes—is unsafe. Such products contain nicotine, which is highly addictive and can harm the developing adolescent brain. Using nicotine in adolescence may also increase risk for future addiction to other drugs. AppHealthCare is working alongside Western Youth Network & the Regional Tobacco Prevention and Control Manager to initiate talks with Ashe County Schools to implement the CATCH My Breath curriculum as well as to install vape detectors in school restrooms and locker rooms to further deter the use of electronic nicotine devices. 

While the results of the YRBS reflect that the number of students who used a vape in the past 30 days has decreased, we are noticing that administrators are increasingly seeking guidance around the vaping use that they are witnessing in the schools.  We continue to explore how to best support our schools around preventing use and promoting cessation among students. 

Medicaid Tobacco Free Policy

Starting December 1, 2022, North Carolina Standard and Tailored Prepaid Health Plans serving Medicaid and uninsured patients will require contracted medical, behavioral health, and some intellectual/developmental disabilities (IDD)/traumatic brain injury (TBI) organizations to provide a 100% tobacco-free campus. On September 7th, 2021, DHHS released a memo to providers advising them of the new tobacco-related policy requirements going into effect December 2022. Daymark Recovery has begun to implement their tobacco-free campus policy and is working to make tobacco cessation part of the standard of care.

Live Vape Free NC

A media campaign aimed to help push vaping cessation among youth launched in Spring 2022 and ran through December 2022.  The campaign is called Live Vape Free and is a digital campaign that targets youth. The ads drive those who click on the ad to a webpage where they can sign up to start the cessation program. This campaign runs in a ten-county region.

Quitline

AppHealthCare staff is able to offer Quitline services to clients by referring them through their online referral platform. QuitlineNC provides free cessation services to any North Carolina resident who needs help quitting commercial tobacco use, which includes all tobacco products offered for sale, not tobacco used for sacred and traditional ceremonies by many American Indian tribes and communities. Quit Coaching is available in different forms, which can be used separately or together, to help any tobacco user give up tobacco.

Tobacco 21

In December 2019, the FDA made a rule to change the age of purchase for tobacco products from 18 to 21.  North Carolina General statute still has 18, which makes enforcement on a local level a gray area. The Board of Education for Ashe County Schools and the AppHealthCare Board of Health passed resolutions in support of a strong Tobacco 21 law

Morbidity and Mortality Changes Since Last CHA

Emerging Issues Since Last CHA

Food Access

Under our Healthy Communities strategy our goal is to increase the number of new community venues providing access to healthy foods and/or the number of existing community venues providing enhanced access to healthy foods. This includes new efforts for implementation as a result of COVID-19. Healthy foods are defined by the USDA as nutrient-dense foods across and within all food groups and are mentioned in the USDA’s Dietary Guidelines for Americans 2020-2025. 

Through our Advancing Equity strategy, our goal is to work with partners from historically marginalized populations to increase healthy food access through community-based policy, environmental change and/or programmatic interventions. We have been actively forming relationships with community partners and touching base on how to best support their efforts. We hope to continue to increase and/or enhance distribution networks supporting local, healthy foods. 

Dr. Stroud at the AppHealthCare Dental Clinic is working with a community member on a community garden that produces fresh produce to distribute at a food pantry for WIC recipients and the Migrant Farmworker population. Stroud hopes to address the food insecurity she witnesses in some of her dental patients and local families. With the help of partnerships, resources, energy and patience, she operates the AppHealthCare Community Dental Garden.

The Ashe County Food and Family Advisory Committee was created to combine the efforts of Cooperative Extension programs (FCS & EFNEP) in Ashe County. Those programs  work to address the nutrition and wellness needs of Ashe County citizens. This committee takes the place of the formerly separate advisory groups. This makes meeting, planning, and organizing more efficient for FCS and EFNEP leaders and more efficient for advisory member participation. The committee is composed of members who have a vested interest in the food access and education of Ashe county residents, whether they are community members,

potential partners, and/or representatives of health and wellness entities within Ashe county. Together, they

strive to address nutrition and wellness needs in Ashe county by promoting access to local foods and community nutrition education opportunities.

Family & Social Supports

Adverse Childhood Experiences

Many health disparities begin early in life with Adverse Childhood Experiences (ACEs). ACEs are potentially traumatic events that can have negative, lasting effects on health and well-being. These experiences range from physical, emotional, or sexual abuse to parental divorce or the imprisonment of a parent. Initiatives such as the Positive Parenting Program and other family interventions through the Partnership of Ashe and the Ashe County Schools are successful at addressing these challenges because they address the whole person in the context of our relationships and local environment. 

Family Based Intervention: Family Connects

Through a collaboration between AppHealthCare and the Children’s Council of Watauga County, Family Connects International Nurse Home Visiting Program has expanded into Ashe County to increase child well-being by helping connect families with newborns to community resources. Using the Family Support Matrix, home visiting nurses assess the well-being of the mother, father, and infant by asking questions regarding general health, infant care, safety, social and emotional support needs, and more. All families in Ashe County are eligible for one home visit by a registered nurse to all parents of newborns up to 12 weeks old born in the service area, up to two additional home visits from the nurse home visitor for families who need additional support, and referrals to resources and services as needed. Family Connects staff have been recruiting at Ashe Memorial Hospital since October of 2021 when staff resumed home visits. As of October 2022, the Family Connects program was reaching 68% of all eligible births in its service area and 100% of all post-visit referrals were being completed.

Family Based Intervention: Positive Parenting Program

Ashe County practitioners continue to implement positive parenting strategies in hopes of reducing serious negative childhood outcomes. AppHealthCare collaborates with Generations Ashe as the local Triple P hub agency and is working towards building capacity and accessibility of Triple P. In 2022, 20 interventions were delivered to families and 30 children were served. By the end of 2022, 14 practitioners had been trained to deliver Triple P services in Ashe. Improved child behavior and decreased parent stress is being reported based on Client Satisfaction Questionnaires received. The Triple P Team is working with partners and practitioners to consistently collect this data to ensure that important feedback loop is sustained.

New/Paused/Discontinued Initiatives Since Last CHA

Paused- Distribution of Resource Cards

In previous years, the Ashe Health Alliance has had a subgroup focused on Mental and Behavioral Health. This subgroup understood that high doses of early adversity significantly increase an individual’s risk of suicide later in life. This group previously worked with the School Health Advisory Council to distribute a Survive and Thrive resource card to ensure that Ashe County’s youngest citizens were aware of mental health services available to them. These cards outlined signs of serious distress, helpful tips for reducing stress, and a list of local and national crisis resources. While the resource cards are still available through AppHealthCare, Ashe Health Alliance has focused on other initiatives related to the selected priorities, including supporting the efforts of Ashe Youth Task Force

Progress on CHIPs

AppHealthCare monitors progress on it's priorities through these programs: 

AppHealthCare Gatekeeper Training  

AppHealthCare Substance Use Interventions 

Morbidity and Mortality Changes Since Last CHA

No notable changes in morbidity and/or mortality have occurred since the last CHA with the exception of increased deaths from COVID-19.

Emerging Issues Since Last CHA

Youth Risk Behavior Survey (YRBS)

AppHealthCare works with the Ashe School Health Advisory Council (SHAC) to disseminate the Youth Risk Behavior Survey (YRBS) on a biennial basis, with 2023 being the most recent dissemination. The 2023 survey included a new question asking about use of Delta 8 and Delta 10, a newer cannabis-derived substance of concern discussed during SHAC meetings. 

Questions included in the survey related to Delta 8/10 include: 

• “During the past 30 days have you used Delta 8 or Delta 10?”

  • 8.3% of AHS students reported using Delta 8/10 during the past 30 days.

• “How much do you think people risk harming themselves physically or in other ways if they smoke Delta 8 or Delta 10?”

  • 19.8% of AHS students reported that they believe that smoking Delta 8/10 poses no risk to harming them physically or in other ways.

Recent SHAC meetings have also included discussions around students and healthy relationships. In the YRBS, the following related questions are asked:

• “During the past 12 months, how many times did someone you were dating or going out with force you to do sexual things that you did not want to do? (Count such things as kissing, touching, or being physically forced to have sexual intercourse.)”

  • 8.4% of AHS students reported that they were forced to do sexual things by someone they were dating. 

• “During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)”

  • 4.8% of AHS students reported that they were physically hurt on purpose by someone they were dating. 

AppHealthCare continues to monitor data trends related to health concerns brought up by school staff and community partners in hopes of contributing to positive change in these areas.

New/Paused/Discontinued Initiatives Since Last CHA

AppHealthCare is no longer monitoring progress for the following initiatives:

Expand Behavioral Health services to farm workers and individuals with Substance Use Disorders.