Executive Summary

AppHealthCare, in collaboration with various agencies and community partners, has released the Community Health Report for Watauga 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 Watauga County will focus on and work to improve from 2020-2023:

• Mental/Behavioral Health
• Family & Social Support
• 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 Watauga County.

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

To view the Community Health Report for Watauga 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.

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 Community Mental Health Project (CMHP) is a Watauga-based coalition made up of agency leaders, clinicians, faith leaders, law enforcement and others who want to improve quality of life and prevent loss of life related to mental health issues.

Who We Serve

With such a diverse group participating in this effort, the target population of this group ranges significantly and many projects are directed towards the general population of Watauga County.

How We Impact

• Raising community awareness around addictions, mental illness, and mental wellness resources and supports through frequent community engagement
• Shattering stigma about mental health and addictions
• Promoting opportunities for conversations about mental health and ways to support our residents

Status of Program for SOTCH Report

As a result of a roadmapping event, CMHP has compiled a webpage with a resource guide that can walk community members through the steps to navigate a range of challenges, as well as links and visual aids for other resources. CMHP is also partnering with Carolina Across 100 to bring more capacity-building tools to Watauga County.

Description

In October 2022, Community Mental Health Project (CMHP) hosted an event called Roadmapping Mental Health in Watauga. The event brought together service providers and community partners to identify social suppots in the community with a goal of improving systems of care for those affected by mental health and/or substance use issues. Final roadmaps will help inform CMHP activities and focus areas moving forward.

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?

Housing is an important social determinant of physical and mental health and wellbeing. The quality and cost of housing can improve or worsen our health in many ways:

• Affordable housing makes more resources available to pay for healthcare and healthy food, which leads to better health outcomes.
• Affordable, quality housing alleviates overcrowding and limits our exposure to environmental toxins.
• Stable and affordable housing supports mental health by limiting stressors related to financial burden or frequent moves, and can offer an escape from an abusive home environment.
• Affordable and accessible housing linked to services enables older adults and individuals with mobility limitations to remain in their homes longer.

(Center for Housing Policy: The Impacts of Affordable Housing on Health: A Research Summary)

Affordable housing was one of the most common responses to an open-ended question asked in the Community Health Opinion Survey regarding resources needed in the community.

Description

In early 2022, a diverse group of community members and key agencies came together to take action on the increasingly complex topic of housing in Watauga County. The group hosted a four-session series over the course of the Spring to discuss the safety, accessibility, and affordability of housing in Watauga. Each session featured community members sharing their personal housing experiences. Participants reviewed key local housing data among participants. 

The Housing Forums led to the creation of the Watauga Housing Council which has recently completed a draft Community Action Plan.

What We Do

Watauga Housing Council envisions all people in Watauga County having secure and stable housing. Watauga Housing Council is working to increase housing supply through partnerships and systemic change.

Who We Serve

Watauga Housing Council is focused on impacting community residents who are cost-burdened.

How We Impact

The WHC fulfills its mission through the following proposed strategic objectives:

• Explore new housing opportunities and solutions with stakeholders & evaluate desired outcomes;

• Coordinate w/ community partners to identify & secure private, local, state, and federal funding and resources;

• Seek, integrate, and disseminate continuous data from target communities w/n Watauga & act as an information hub; and

• Develop & maintain backbone support for long-term collective impact effort on housing.

Status of Program for SOTCH Report

Watauga Housing Council (WHC) formed in June 2022 as a collective impact initiative resulting from a series of community-wide housing forums. WHC used the Results-Based Accountability (RBA) Framework to identify a population-level desired community result, quantitative indicators, the community’s housing “story,” housing assets/barriers, stakeholders, and a first set of achievable action steps. The WHC is structured into 3 committees to conduct work: Community Engagement (gathers targeted community input about housing needs/assets and supports communities to implement solutions), Housing Solutions (explores, prioritizes, and executes action steps), and Government Relations  (focuses on identifying policy changes and funding opportunities that can increase the supply of housing for cost-burdened Watauga residents). The WHC also is supported by a charter Board of Directors, a Communications Workgroup, and a Data Workgroup to facilitate its efforts.  

Achievements of the WHC in 2023 include–

• Community Engagement:  hosted two community dinners/conversations, collected & disseminated data for those communities, developed a Memorandum of Understanding with other community partners, and participated in related community events;  

• Housing Solutions:  reviewed and prioritized action steps, facilitated two employer-led housing conversations, hosted a potential ASU BCHS & UNC-Health housing collaboration, supported a resident-owned trailer community initiative; participated in other community-driven housing initiatives; 

• Government Relations:  oversaw development of a backbone structure for the WHC, reviewed population indicators with the Council, developed a purpose statement  & focus on local and state policy and funding opportunities; 

General Achievements:  voted on a mission statement, developed a charter Board of Directors, received approval of Articles of Incorporation, submitted 501c3 paperwork to the IRS, launched a website, and developed a preliminary social media plan.

Why Is This Important?

Social connectivity is a very important predictor of health. Social connectivity includes spending time with friends and family, taking part in group activities, or having a sense of community. Having strong social ties supports a person’s physical and mental health in many ways, from lowering rates of disease to decreasing stress during major life transitions. One recent study found that those who lacked supportive relationships had a fourfold increased risk of dying six months after open-heart surgery (Whole Health Action Management Peer Support Training Participant Guide).

Early childhood experiences have a great impact on health, educational achievement and financial security. Adverse childhood experiences such as abuse, neglect, or poverty can negatively affect brain development and increase a person’s risk for physical and behavioral health problems later in life. Providing children with safe and stable homes, relationships, and environments can protect against the impact of adverse childhood experiences, improve health, and generate increased financial security (NC Child Health Report Card 2018).

What We Do

The Mother-Baby Home Visiting Program increases child well-being by helping connect families with newborns to community resources.

Who We Serve

All families in Watauga 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. Mother-Baby staff have been recruiting at Watauga Medical Center since October of 2021 when staff resumed home visits.

How We Impact

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.

Status of Program for SOTCH Report

Mother-Baby Home Visiting Program, previously the Family Connects Home Visiting Program, made the transition this year from being a shared program through The Children's Council and AppHealthCare, to being fully housed within AppHealthCare. While we have transitioned from the Family Connects model, AppHealthCare is committed to providing these essential home visiting services to the community long-term.

What We Do

AppHealthCare works with community partners and lead agencies to promote and support implementation of positive parenting strategies in an effort to better support parents and reduce child maltreatment. 

Who We Serve

The Positive Parenting Program team works with practitioners across the county to serve parents in a variety of settings, including non-profit and government agencies, schools, private providers settings, and more.

How We Impact

The Positive Parenting Program offers evidence-based strategies for responding to common behaviors in children. Practitioners work with parents to determine which strategies work best for their family. Parents feel more empowered to respond to their child's behavior and support their child's needs.

Status of Program for SOTCH Report

In 2023, 45 caregivers/parents received in-person support sessions from local providers throughout our district. Additionally, we saw active engagement from 86 caregivers/parents across Alleghany, Ashe, and Watauga Counties on Triple P Online - a resource available at no cost to families in North Carolina. AppHealthCare also hosted 3 Triple P workshops to enhance practitioner's skill and confidence, and trained four new practitioners within the district, reinforcing our commitment to empowering families and fostering positive parenting practices throughout our communities.

Why Is This Important?

Early childhood experiences have a great impact on health, educational achievement and financial security. Adverse childhood experiences such as abuse, neglect, or poverty can negatively affect brain development and increase a person’s risk for physical and behavioral health problems later in life. 

Providing children with safe and stable homes, relationships, and environments can protect against the impact of adverse childhood experiences, improve health, and generate increased financial security. Schools also play an important role in addressing childhood trauma. The Watauga Compassionate Community Initiative (WCCI) is a group of multidisciplinary stakeholders that is working to address childhood trauma in the county.

What We Do

The mission of WCCI is to promote health and resiliency in our community and to effectively prevent, recognize, and treat trauma by creating safe, stable, nurturing environments and relationships through education, advocacy and policy change.

Who We Serve

WCCI works at the community level as a convener to impact individuals, families, communities, as well as systems to address trauma and adversity.

How We Impact

WCCI works to inform, inspire, and empower community members to prevent harm, promote well-being, and heal from adversity. WCCI does this through conferences, community presentations, and local outreach events to determine current needs and assets.

Status of Program for SOTCH Report

While AppHealthCare's role with WCCI has shifted, community health staff are still involved and WCCI continues to be active. 

Why Is This Important?

Employment is an important factor for the health status of our community. Overall, people who are employed are healthier than those who are not employed, regardless of gender, age or disability status (Thomas & Ellis). Health also has an impact on a person’s desire to work and their likelihood of being hired or keeping a job (The Impact of Employment on the Health Status and Health Care Costs of Working-Age People with Disabilities). It is important to consider that improving employment opportunities for working-age people can improve health status and decrease healthcare costs in a community. Employment can improve health by increasing social capital, enhancing psychological well-being, providing income, and reducing the negative health impacts of economic hardship.

What We Do

STABLE Workplaces strives to better deliver resources to the business sector through unified messaging, collaborative training efforts, toolkit development and incentivised participation.

Who We Serve

STABLE Workplaces works with a range of community partners to support any employer of place of employment.

How We Impact

STABLE Workplaces is currently working on developing a web page, a STABLE 101 presentation to orient workplaces to the offerings of STABLE and its partners, and an incentive program and/or designation that workplaces can gain through participation in trainings & utilization of resources.

Status of Program for SOTCH Report

The driving coalition behind STABLE Workplaces spent 2023 preparing for program launch by building a webpage, putting together a STABLE 101 presentation for initial engagement of program participants, and designing an tiered designation system and incentive structure. The program is due to launch in 2024.

Progress on CHIPs

Public Health Priorities

The Watauga Compassionate Community Initiative collaborative, which focuses on promoting health and resiliency in our community and to effectively prevent, recognize, and treat trauma by creating safe, stable, nurturing environments and relationships, selected the health priorities in August 2021. These priorities were chosen based on the 2020 Watauga County Community Health Assessment. The public health priorities identified for Watauga County include mental and behavioral health, family and social support, and housing.  

Health Priority: Mental and Behavioral Health

Update to Local Community Objectives

Community Mental Health Project

The Community Mental Health Project (CMHP) is a Watauga-based coalition made up of agency leaders, clinicians, faith leaders, law enforcement and others who want to improve quality of life and prevent loss of life related to mental health issues. With such a diverse group participating in this effort, the target population of this group ranges significantly and many projects are directed towards the general population of Watauga County. The latest activity of the Community Mental Health Project involved producing a comprehensive website of local resources and continuing to facilitate honest conversations around mental health to reduce stigma. The group is exploring ways to connect the resources website with NCCare360, the statewide referral network. Additionally, the group is planning an event to roadmap mental health in Watauga County. This event will address gaps and barriers to accessing mental health locally.

Behavioral Health Interventions

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, Watauga County continues to improve access to counseling, referral services, case management, and crisis management. 

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, substance misuse, and primary care services has 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. 

School Based Behavioral Health

AppHealthCare works with the Watauga 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. The Assessment, Support, & Counseling (ASC) Center is a valuable program that supports Watauga 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 Watauga 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

The Watauga School Health Advisory Council (SHAC) understands that high doses of early adversity significantly increase an individual’s risk of suicide later in life. The group has discussed distributing a Survive and Thrive resource card to ensure that Watauga 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.

Watauga Substance Action and Prevention

Watauga Substance Action and Prevention is a data-driven, evidence-based, multi-sector coalition with a goal to reduce youth substance use and abuse in Watauga County, North Carolina. WSAP utilizes the Seven Strategies for Effective Community Change and the Drug-Free Communities Model. The areas of focus are alcohol, tobacco and prescription medications. They continue to study the data procured by the YRBS and how it relates to the youth mental health and substance use in Watauga County Schools. Alongside this, they actively perform alcohol purchase surveys in the community which lessens the chance of youth being able to purchase alcohol without having a valid ID. 

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 Watauga 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: Family & Social Support

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. ACEs are also associated with chronic, long-term health issues such as chronic stress and diabetes. Initiatives such as the Positive Parenting Program, Family Connects home visiting program, and the Watauga Compassionate Community Initiative are successful at addressing these challenges because they address the whole person in the context of our relationships and local environment. 

Update to Local Community Objectives

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 continues 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 Watauga 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 Watauga Medical Center 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

Watauga 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.

Building Community Resilience/Resilience Catalysts

AppHealthCare was selected in 2019 to partner with George Washington University, National Association of County and City Health Officials (NACCHO), and American Public Health Association (APHA) as a Chief Health Strategist, or Resilience Catalysts site, to push forward initiatives that address the Pair of ACEs. Resilience Catalysts foster integration of cross-sector and community services and community-wide prevention by leveraging a public health approach to prevent the Pair of ACEs with a focus on adverse childhood experiences (ACEs), opioid misuse, and suicide. One of AppHealthcare's focus areas for the Resilience Catalysts project is employment because we know that economic stability leads to improved health outcomes for individuals and their families. AppHealthcare is working with Watauga Compassionate Community Initiative (WCCI) and other partners to design a toolkit for businesses to become trauma-informed. This resource will help businesses to better support their employees in a variety of ways.

Health Priority: Housing

Update to Local Community Objectives 

Watauga Housing Forum

Issues related to housing can impact community members in a variety of ways, including impacting long-term health outcomes. A diverse group of community members and key agencies have come together to take action on the increasingly complex topic of housing in Watauga County. The group hosted a four-session series to discuss the safety, accessibility, and affordability of housing in Watauga. Each session featured community members sharing their personal housing experiences. Participants reviewed key local housing data among participants. 

The Housing Forums led to the creation of the Watauga Housing Council which has recently completed a draft Community Action Plan. Through a careful voting process based on the criteria of value, reach, leverage, and specificity, the following actions have been selected as the most powerful actions to turn the curve on housing in Watauga:

• Ordinance to allow for tiny-home & RV home communities
• Zoning Code Change/Incentive Program 
• Renovate publicly-owned property, not being used, for affordable housing
• Town/county incentives/supports to property owners to rehab housing for affordable rentals
• Individual church-led housing initiatives (ie. Caldwell Presbyterian/Open Hearts Place)

In August 2022, the Housing Council will form committees and determine initial action steps. 

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. Programs such as the High Country Food Hub operated by Blue Ridge Women in Agriculture are making the availability of fresh food and produce more accessible to those who are in more rural parts of the county. They now have satellite pick up locations in Vilas/Zionville and Deep Gap.  We are also supporting outreach efforts for the Double Up Food Buck program which matches your SNAP/EBT dollars so you get twice the amount of fruits and veggies.

The Watauga Farmers Market opened early this season at the beginning of April. They have expanded their hours until 1pm every Saturday allowing more people to be able to attend. Located at Horn in the West, the market is continuously growing and AppHealthCare is supporting efforts to optimize operations. A connection has also been made between the market and Q’Pasa Appalachia in hopes that the market will be more accessible to the Latino community. Plans include creating more Spanish signage as well as potentially hosting a Latin day at the market. 

F.A.R.M. Full Circle is a food recovery and redistribution program of F.A.R.M. Cafe. They collect imperfect fruits and vegetables, over-ordered food items, and other products at risk of going to waste from local grocers, farmers, and small businesses. Each week, volunteers prepare ready-to-eat meals, meal kits, and other value-added products using recovered foods. Products are distributed in two ways. Primarily they distribute fresh produce, prepared meals, and meal kits to nonprofit and faith-based organizations serving food insecure individuals. A weekly selection of meals and side dishes are also available on a donate-what-you-can basis at F.A.R.M. Cafe and High Country Food Hub. AppHealthcare has been able to support F.A.R.M. Cafe with materials for a new prep kitchen in their building, which will add much needed capacity to their outreach efforts.

The Watauga Food Access and Security Workgroup is continuing to find innovative ways to connect with those in the community surrounding this topic. Currently the workgroup is working on a skill share series. Potential topics include gardening, bulk food prep, fermentation, edible landscaping and nutrition. These skill share series opportunities will be free and the limited spots would be given to those who could benefit the most from in the community.

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 Watauga 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

Community Mental Health Project

The Community Mental Health Project (CMHP) is a Watauga-based coalition made up of agency leaders, clinicians, faith leaders, law enforcement and others who want to improve quality of life and prevent loss of life related to mental health issues. With such a diverse group participating in this effort, the target population of this group ranges significantly and many projects are directed towards the general population of Watauga County. In the Spring of 2022, CMHP completed a Results-Based Accountability action planning exercise and in the Fall hosted a roadmapping event to help determine gaps and barriers to accessing mental health services locally. Recent activities of the coalition include making revisions to the website to make it more accessible, developing a logo that will be recognizable in the community, and restructuring into workgroups. Going into 2023, the workgroups will develop goals around publicity and education of the community, case management and obstacles to care, and resources/education for providers. 

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.  

School Based Behavioral Health

AppHealthCare works with the Watauga 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. The Assessment, Support, & Counseling (ASC) Center is a valuable program that supports Watauga 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 Watauga 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.

Watauga Substance Action and Prevention

Watauga Substance Action and Prevention is a data-driven, evidence-based, multi-sector coalition with a goal to reduce youth substance use and abuse in Watauga County, North Carolina. WSAP utilizes the Seven Strategies for Effective Community Change and the Drug-Free Communities Model. The areas of focus are alcohol, tobacco and prescription medications. They continue to study the data procured by the YRBS and how it relates to the youth mental health and substance use in Watauga County Schools. Alongside this, they actively perform alcohol purchase surveys in the community which lessens the chance of youth being able to purchase alcohol without having a valid ID. Other successes of the group include establishing the Watauga Youth Council, installing the first Drug Drop Box in Seven Devils, using billboards to raise awareness around underage drinking, and building coalition capacity through Reconnect for Resilience training.

Health Priority: Family & Social Support

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. ACEs are also associated with chronic, long-term health issues such as chronic stress and diabetes. Initiatives such as the Positive Parenting Program, Family Connects home visiting program, and the Watauga Compassionate Community Initiative are successful at addressing these challenges because they address the whole person in the context of our relationships and local environment. 

Update to Local Community Objectives

Watauga Compassionate Community Initiative

Watauga Compassionate Community Initiative (WCCI) is a local coalition devoted to promoting health and resiliency in the community and effectively preventing, recognizing, and treating trauma. WCCI achieves this by creating safe, stable, nurturing environments and relationships through education, awareness, advocacy and policy change. In 2022, WCCI conducted six trainings on trauma and resilience for 45 individuals and organizations and created four new trainings for organizations to further engagement. Members of the group also created 30 newsletters and compiled and developed a 33-page North Carolina Proclamation Week Resource Guide that was distributed statewide. Other activities included website upkeep and data compilation. Lastly, WCCI participated in three collaborative mini events across the county to inform, connect, and assess needs and assets.

Building Community Resilience/Resilience Catalysts

AppHealthCare was selected in 2019 to partner with George Washington University, National Association of County and City Health Officials (NACCHO), and American Public Health Association (APHA) as a Chief Health Strategist, or Resilience Catalysts site, to push forward initiatives that address the Pair of ACEs. Resilience Catalysts foster integration of cross-sector and community services and community-wide prevention by leveraging a public health approach to prevent the Pair of ACEs with a focus on adverse childhood experiences (ACEs), opioid misuse, and suicide. One of AppHealthcare's focus areas for the Resilience Catalysts project is employment because we know that economic stability leads to improved health outcomes for individuals and their families. 

STABLE Workplaces

STABLE Workplaces is a new initiative in Watauga County with a vision of thriving workplaces sustained by a stable workforce. STABLE Workplaces stands for 'Staff Training and Business Leadership for Evolving Workplaces'. The effort was born out of an event back in August which convened area agencies and partners alongside Watauga County business owners and employers to discuss the possibility of an ongoing collaborative effort toward more resources in the workplace. The August event built on years of data collection efforts to better understand challenges around workforce development through the perspectives of local stakeholders, including business leaders and staff. STABLE Workplaces recognizes that the business sector is facing unprecedented recruitment and retention challenges alongside complex challenges among staff (family needs, mental health and substance use concerns, lack of housing, etc.). STABLE is exploring ways to better deliver resources to the business sector and other employers through unified messaging, collaborative training efforts, toolkit development and incentivized participation. The group is currently working on developing a web page, a STABLE 101 presentation to orient workplaces to the offerings of STABLE and its partners, and an incentive program and/or designation that workplaces can gain through participation in trainings & utilization of resources.

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 continues 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 Watauga 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 Watauga Medical Center 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

Watauga County practitioners continue to implement positive parenting strategies in hopes of reducing serious negative childhood outcomes. Healthy children equal healthy adults later in life. AppHealthCare collaborates with The Children’s Council as the local Triple P hub agency. In 2022, 177 interventions were delivered to families and 391 children were served. 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.

Health Priority: Housing

Update to Local Community Objectives 

Watauga Housing Forum

Issues related to housing can impact community members in a variety of ways, including impacting long-term health outcomes. In early 2022, a diverse group of community members and key agencies came together to take action on the increasingly complex topic of housing in Watauga County. The group hosted a four-session series to discuss the safety, accessibility, and affordability of housing in Watauga. Each session featured community members sharing their personal housing experiences. Participants reviewed key local housing data among participants. 

Watauga Housing Council

The Housing Forums led to the formation of the Watauga Housing Council (WHC) in June 2022 as a collective impact initiative. All Watauga Housing Forum participants & other community members were invited to join. WHC used the Results-Based Accountability (RBA) Framework to identify a population-level desired community result, quantitative indicators, the community’s housing “story,” housing assets/barriers, stakeholders, and a first set of achievable action steps. The WHC is structured into 3 committees to conduct work: Community Outreach (continues to gather targeted community input about housing needs/assets), Housing Solutions (explores, prioritizes, and executes action steps), and WHC Structure & Fiscal/Sustainability (focuses on backbone for the WHC & funding and project opportunities). Achievements of WHC in 2022 include:

• Securing a grant to support communication outreach via social media, communications, & website development
• Conducting its first targeted community conversation in November 2022 at a rural church
• Researching initial community-identified action steps as well as other potential action steps to be assigned in 2023
• Exploring different backbone models to support WHC collective impact & voting to form a 501c3 organization
• Developing and distributing a housing survey to the community–89 completed surveys collected to date

Morbidity and Mortality Changes Since Last CHA

Emerging Issues Since Last CHA

Substance Use and Misuse Prevention

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 Watauga County was 20 out of 100,000 people in 2020. This represents 11 people in Watauga 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 Watauga County was 39 out of 100,000 people in 2020, with a population of 54,000. This represents 22 emergency department visits by Watauga residents for overdose in that year.

As a result of the opioid settlement, Watauga County government is set to receive $3,024,789 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, Watauga 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 Watauga County Commissioners approved the utilization of $300,000 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, Watauga 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) Harm reduction, 2) Connections to care, 3) Support for people in treatment and recovery, 4) Treatment, and 5) Addressing the needs of criminal-justice involved persons.

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 Watauga County, North Carolina. In addition, this RFP builds capacity and local  infrastructure to respond to the overdose crisis in Watauga 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: (424 unique, 3510 follow-up contacts)
• Total syringes returned: 48,000 
• Total naloxone kits distributed: 2,290 
• Number of unique justice-involved persons served: 103
• 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: 59
• 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), 380 kits distributed to 350 participants
• Number of average contacts with each individual served: 14
• Number of individuals connected to medical, social services, emergency housing, transportation, food, treatment, behavioral health, SSP: 339

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 Watauga County Schools and the AppHealth Care Board of Health passed resolutions in support of a strong Tobacco 21 law.

Community Justice

Watauga Community Justice Coalition

The Watauga Community Justice Coalition (WCJC) is an inclusive group of community members and stakeholders working to implement restorative justice principles in the High Country through a set of collaboratively developed priorities. WCJC formed out of the planning group that developed and implemented Law Enforcement Assisted Diversion (LEAD) in Watauga County. This planning group included representatives from the Watauga County Sheriff’s Office (WCSO), the Mediation and Restorative Justice Center (MRJC), AppHealthCare, the Office of the District Attorney, Watauga County Clerk of Court, Social Services, Daymark Recovery Services, Vocational Rehabilitation, and the High Country Council of Governments. The group worked to create agreements, shared understandings, policies and procedural guidelines for the LEAD program, which was established in 2020 by MRJC, with partners WCSO and AppHealthCare. Once LEAD was implemented, the planning group decided to continue meeting and working together, re-branding themselves as WCJC and adopting priority goals identified through the 2019 Watauga Sequential Intercept Mapping (SIM) process. The SIM event, led by trained external facilitators, was hosted by the LEAD Planning group, MRJC, and AppHealthCare for a diverse group of community stakeholders. The original five priorities were as follows: 1. Develop and support a trauma-informed criminal justice and crisis response system. 2. Cross-train law enforcement / 1st Responders & behavioral health providers. 3. Develop a local reentry council. 4. Coordinate effective release planning with hospitals and area facility-based crisis centers. 5. Develop a post-booking jail diversion program.    

In 2022, WCJC reviewed community progress in relation to the identified goals and revised these priorities, outlining a new action plan for 2023 with four main goals/priorities. The revised priorities are as follows: 1. Develop sober living and transitional housing in Watauga County. 2. Repair identified gaps in the community’s behavioral health safety net. 3. Develop and support a trauma-informed criminal justice and crisis response system. 4. Build an enhanced recovery ecosystem that allows for successful reentry. This group’s accomplishments since inception include establishing a LEAD program in Watauga County, hosting a Sequential Intercept Mapping process, hosting presentations and guest speakers, supporting the development of the High Country Reentry Collaborative, beginning a Results-Based Accountability process, creating collaborative community action plans, and building new partnerships.

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. Programs such as the High Country Food Hub operated by Blue Ridge Women in Agriculture are making the availability of fresh food and produce more accessible to those who are in more rural parts of the county. They have a well established satellite pick up location in Deep Gap.  We are also supporting outreach efforts for the Double Up Food Bucks program which matches your SNAP/EBT dollars so you get twice the amount of fruits and veggies.

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. 

Q'Pasa Appalachia, Watauga County Farmers Market, AppHealthCare, WIC & Blue Ridge Women in Agriculture have partnered to develop an educational vlog that would help those who speak Spanish feel more comfortable going to the local farmers markets and using the Farmers Market Nutrition Program (FMNP) check from WIC. The vlog will walk viewers through the process of how to use the Double Up Food Bucks program and what you can purchase.

AppHealthCare has begun exploring the NC Healthy Food Retail Designation supported by the Advancing Equity and Healthy Communities programs. Initial steps include forming relationships with local stores to see what support they need in offering healthy food options, particularly in areas where there is not a big box grocery store.

New/Paused/Discontinued Initiatives Since Last CHA

Paused- Distribution of Resource Cards

In recent years, AppHealthCare and the School Health Advisory Council have discussed distributing a Survive and Thrive resource card to ensure that Watauga County’s youngest citizens were aware of mental health services 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. While the resource cards could still be an area of focus in the future, AppHealthCare has focused on other initiatives related to the selected priorities, including supporting the efforts of Watauga Substance Action and Prevention.

Progress on CHIPs

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

AppHealthCare Gatekeeper Training 

Community Mental Health Project 

Watauga Housing Council 

STABLE Workplaces 

Positive Parenting Program 

Mother-Baby Home Visiting Program

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

Opioid Settlement

In November 2022, Watauga 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 Watauga County Commissioners approved the utilization of $300,000 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, Watauga County considered 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 was given to projects that align with the top 5 focus areas determined through RBA action planning: 1) Harm reduction, 2) Connections to care, 3) Support for people in treatment and recovery, 4) Treatment, and 5) Addressing the needs of criminal-justice involved persons.

For the 2023-2024 fiscal year, Watauga County authorized use of opioid settlement funds for the following projects:

• AppHealthCare for the purchase of a mobile health bus as well as expansion of the Mother-Baby Program (previously Family Connects) to serve families impacted by substance use disorder

• Mediation & Restorative Justice Center/Homestead Recovery Center for Recovery Friendly Housing

• High Country Community Health for peer support services as well as expanded medication-assisted treatment services

Additionally, funds will be used for further collaborative strategic planning to ensure a strong foundation for future investments. 

New/Paused/Discontinued Initiatives Since Last CHA

AppHealthCare is no longer monitoring progress for the following initiative. However, the iniative is still active and has AppHealthCare's support and participation:

Watauga Compassionate Community Initiative