Community Health Needs Assessment 2016

EAST TENNESSEE CHILDREN’S HOSPITAL
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Form No. 31607 (06/16)
Community
Health Needs
Assessment
2016

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Table of Contents
Introduction................................................................................................................................................................3
2016 executive summary.......................................................................................................................................4
Community served...................................................................................................................................................5
Service area defined
Demographic data
Review of 2013 implementation strategy, outcomes..................................................................................7
Methodology and process for 2016 CHNA....................................................................................................11
Planning
Gathering and analyzing information
Key informant interviews
Focus groups
Community survey and summary
Primary data summary..........................................................................................................................................12
Secondary data summary....................................................................................................................................12
Findings and conclusions.....................................................................................................................................13
Identifying health needs
Selecting priorities
Gathering, tracking and reporting community benefit efforts
Current resources
Implementation strategy 2016...........................................................................................................................14
Community needs not addressed.....................................................................................................................18
Request more information, written comments solicited..........................................................................18
Appendices

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Introduction
For 79 years, physicians, staff members and volunteers at East
Tennessee Children’s Hospital (ETCH) have provided the best
care to children from across our region. However, our dedication
to the community extends beyond medical care. An integral
part of our mission is to improve the health of children through
exceptional wellness and education. In East Tennessee, we
provide services, support and education to the community
through various projects and programs. These programs promote
safety, healthy lifestyles and specialized care beyond what
Children’s Hospital offers within its walls. We strive to ensure
that community health is more than just words in our mission
statement.
In a broad sense, Children’s Hospital strives to improve the
health status of the children in our region. To better understand their needs, we formally review
their health using information obtained through analysis and interview with both families and
community leadership. Children’s Hospital conducted our first formal Community Health Needs
Assessment (CHNA) in 2013. The analysis identified the need to address issues associated with
access to care, behavioral health, childhood obesity, parent education and dental care. The
findings of the assessment provided a direction for our community mission and helped develop
the scope of the work we do in the community. Importantly, this assessment provided an
opportunity for Children’s Hospital to partner with those in the community who shared a similar
concern and offered an opportunity to leverage partnerships effectively, promote communication
and to be efficient with resources.
The feedback we receive from key informants, focus groups, other stakeholders and research of
published data is critical to understanding the health needs and resources within our community.
As you read about our activities associated with the assessment conducted in 2013 as well as the
information we have gleaned as a result of our 2016 analysis, I think you will agree with me that
although we have accomplished a lot, there is still much more to do. If you have questions or
suggestions based on your review of this report, please feel free to contact the Children’s Hospital
Community Benefit Department at (865) 541-8532. We have an ongoing commitment to listen to
and work with community members, leaders and organizations to help improve the lives of the
children in our area.
We would like to thank all individuals who participated in the needs assessment process.
Combining the assets of the local community we serve with the mission, dedication and vision
of Children’s Hospital, we have confidence that we will continue to address health priorities of
children in our communities.
Keith Goodwin, President/CEO

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2016 Executive Summary
The 2010 Patient Protection and Affordable Care Act introduced reporting requirements for
not-for-profit hospitals to maintain their 501 (c) (3) tax-exempt status. Effective for tax years
beginning after March 23, 2012, each hospital must:
1. Conduct a CHNA at least once every three years.
2. Develop an implementation strategy to address identified needs.
3. Report on outcomes of efforts from strategies implemented.
4. Report the results of each CHNA publicly.
At Children’s Hospital, children are our only concern, and that drives our mission to improve
their health though exceptional, comprehensive family-centered care, wellness and
education. It is a mission that centers on a profound and unchanging commitment to the
physical, educational and emotional needs of each child. The CHNA is the foundation for
improving and promoting the health status of our community’s children. The planning,
activities and data review necessary for the development of the most recent assessment took
place beginning December 2014 and extended through spring 2016 and includes state and
county-specific data collection and primary data obtained through surveys and interviews
with individuals from local communities.
Throughout the CHNA, high priority was given to determining the health status and available
resources within Knox, Anderson, Blount, Sevier and Jefferson counties. These counties were
identified as core counties based on patient population data.
After careful evaluation of all primary and secondary data, health priorities were identified.
The remainder of this assessment is dedicated to reviewing the outcomes of the 2013
implementation strategy, identifying our service area, reviewing demographic data through
primary and secondary resources, explaining our process and methods for the assessment,
identifying the health needs selected as priorities, evaluating current resources, identifying
our implementation strategy and reporting on community needs not addressed and why.

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Where and who we serve
Service area defined
Children’s Hospital is certified by the State of Tennessee as a Comprehensive Regional
Pediatric Center (CRPC). This certification acknowledges Children’s Hospital’s ability to provide
a wide range of specialized pediatric medical and surgical services to acutely ill and injured
children. An additional responsibility involves working with hospitals within our region to
ensure they have a basic capability to provide care to children who may present at their
facility. Emergency Department physicians and nurses provide onsite education to hospitals
and physician groups in the regions. Training includes advanced CPR techniques, line
insertion, trauma care, injury prevention programs and education.
Upon examination of patient admission data, Children’s Hospital identified five area counties
to focus on gathering information. Although Children’s Hospital serves the entire East
Tennessee region as a CRPC, nearly half (%) of Children’s Hospital’s total patient visits during
the 2015 fiscal year were from Knox County residents, making Knox County Children’s
Hospital’s primary service area. For purposes of this CHNA, Blount County, Sevier County,
Anderson County and Jefferson County were included as we gathered and analyzed
community health needs.
Patient demographic data
Children’s Hospital serves children and young adults, newborn to 21.
Age distribution for FY 2015 Race distribution for FY 2015
0-3 39% Asian – 1%
4-7 20% American Indian – less than 1%
8-11 16% Black – 9%
12-16 19% Black/Hispanic – less than 1%
17-19 5% Bi-racial – 5%
Above 19 2% Hispanic – 5%
Other – 3%
White – 77%
White/Hispanic – 1%

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Payer mixFinancial highlights
Primary service area
Cost to operate Children’s Hospital
$577,303 a day
$210,715,622 a year
71,974 unique patients
144,783 patient visits
142,332 patient visits from Tennessee
1,068 patient visits from Kentucky
547 patient visits from Virginia
836 patient visits from other states
Patient population
Statistics from Fiscal Year 2014-15

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2013 Implementation strategy review and
summarization
The 2013 CHNA conducted by Children’s Hospital revealed the following five health priorities
to address for a three-year period though a focused implementation strategy:
1. Access to care
2. Behavioral health
3. Childhood obesity
4. Parent education
5. Dental care
The Children’s Hospital Board of Directors approved for several existing programs to be
developed or enhanced in response to these priorities.
Children’s Hospital Childhood Obesity Coalition
(Formerly Knoxville Area Coalition on Childhood Obesity)
This program works to improve the health of children through a community-wide partnership.
The goal of the coalition is to reverse the incidence of childhood obesity. In 2013, Children’s
Hospital committed to continuing this program through financial support for both staffing
and program costs.
Programs have been strategically developed in areas of East Tennessee where obesity is more
common and healthy food options are less accessible. The data used to define greatest need
was generated through analysis of body mass index (BMI) readings provided through the
school systems. By developing and implementing these programs, children and families learn
to incorporate a healthy regimen into their daily routine. Community partners are essential to
successful programming. Key partners in program execution and expansion are Coordinated
School Health coordinators, school systems and preschools. These partners play a pivotal role
in the capacity to support the program development, positively impacting the sustainability
of life-long habits of healthy behaviors among children and families.
With increased funding, both hospital and grant-based, the Children’s Hospital Obesity
Coalition has been able to offer the following programs:
• Kids Can Bike: a seven-week program held twice a week that teaches the participants
about bike upkeep, bike safety and greenway etiquette. Kids Can Bike is partnership
with the City of Knoxville Parks and Recreation.
• Health Happens: a three-part program targeting preschoolers, their parents and their
teachers. The preschoolers participate in a 12-week program, receiving 30 minutes of

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nutrition education and 30 minutes of instructor led physical activity. The parents
are invited to participate in six classes that include nutrition and physical activity
information. The teachers participate in two meetings that encourage their center to
participate in the Let’s Move Childcare Initiative, a national program that encourages
and supports child care and early education to make positive changes. During these
meetings, the instructors lead the teachers in creating an action plan and support
them during the implementation process.
• Healthy Kids Club: a 12-week program that targets students from kindergarten
to fifth grade. Weekly, up to 50 children participate in physical activity, nutrition
education and taste tests. The goal of Healthy Kids Club is to familiarize children
with basic nutrition concepts, expand their knowledge and consumption of fruits
and vegetables, increase physical activity and learn a lasting, playful approach to a
healthy lifestyle.
• The Grub Club: promotes healthy lifestyles to area elementary school students
through education about real food–where it comes from, how it grows the
nutritional benefits and its variety of flavors while providing physical activity in the
garden.
The Children’s Hospital Obesity Coalition has educated more than 26,000 children about the
benefits of nutrition and physical activity since 2013, and evaluations show an increased
awareness about health issues among children reached. The Knox County Schools reports
annually on BMI scores and indicates a decline in BMI scores taken in school-age children.
The average BMI scores for a selected age group for the school year 2011-2012 was 33.78
percent and for the school year 2014-2015 was 29 percent. While some success has been
achieved, we recognize there is much more work to do.
Project ADAM Tennessee
Project ADAM Tennessee was launched by Children’s Hospital in 2011 with the mission of
placing Automated External Defibrillators (AEDs) in elementary and middle schools and
instructing school personnel in the proper use of CPR and AEDs in Knox County. The goal
is to make AEDs available to all area schools and work toward eliminating sudden cardiac
death in children and community members through education and prevention. Since
starting the program, the focus has expanded beyond Knox County and now includes
support to schools and programs throughout the state. To date, Project ADAM has helped
fund or co-fund 131 AEDs, trained 950 individuals to administer CPR in schools and
conducted 129 AED heart-safe drills in area schools.
Partnerships with Knox County Schools, the University of Tennessee and Coordinated School
Health help Project ADAM Tennessee continue to make a difference. Opportunities continue
to promote the program’s expansion. Recently, a new Tennessee State law known as
“Sudden Cardiac Arrest Prevention Act”has spurred a flurry of new interest in Project ADAM
that will set a course for this program for years to come.

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Children’s Hospital Injury Prevention (Safe Kids Coalition of the Greater Knox Area)
Children’s Hospital is the lead organization for Safe Kids of the Greater Knox Area, a local
chapter of the international non-profit Safe Kids Worldwide. This program is dedicated to
preventing injuries in children, which is the number one killer of children in the United
States. The injury prevention program concentrates on reducing injuries from motor vehicles,
sporting activities, drowning, falls, burns and poisonings.
With dedicated funding and increased resources from Children’s Hospital and support grants,
over the last two years the program distributed 3,920 helmets and 820 car seats, conducted
106 car seat inspection events and provided injury prevention education programs to more
than 30,000 participants. While it is difficult to evaluate the impact of programs of this
nature, there is an implied success with the continued pre-and post-program evaluation,
participation of coalition members and community interest.
Children’s Hospital Developmental Behavioral Center
The Developmental Behavioral Center opened in January 2014. The center diagnoses
conditions such as ADHD, autism, depression, anxiety, obsessive compulsive disorder and
tic disorder. It provides medical management for these conditions and serves to coordinate
other appropriate services such as counseling, speech or occupational therapies. The program
works in coordination with the patient’s primary care physicians and strives to help them
determine appropriate referrals.
Currently there is one physician and one nurse practitioner on staff. Also on the team are
three nurses who in addition to their nursing duties provide support to families about
parenting skills. Since opening, the center has a total of 5,198 patient visits; 866 of those visits
were new consultations. Of those new consultations, 76 were with autism spectrum disorder,
30 with development delay, 350 with ADHD, 101 anxiety and 20 with depression.
Though still in its infancy, it is clear that this program is beginning to make an impact on
children who have previously been underserved in our community.
Knox County School nurse program in Title 1 Schools
“Title 1”is a federal status applied to schools that operate in high poverty areas. Additional
funds are distributed to Title 1 schools to operate programs for children who need extra
educational assistance to perform at the appropriate level for his or her age and grade. The
school nurse is central to coordination of health care services, health screenings, health and
dental hygiene promotion and education. School nurses have a broad knowledge base and
use their expertise to assist students and families in developing healthy lifestyle choices,
health care referrals, assistance in obtaining medical insurance and case management for
the chronically and acutely ill. The school nurse is one of the main collaborative partners in
a school; therefore, having a full-time registered nurse in each Title 1 elementary school is
paramount to student academic achievement, health and wellness.

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In the 2013-14 school year, Children’s Hospital provided a three-year grant to fund 10
registered nurses in 13 Title 1 schools at an average cost of $500,000 annually. Knox County
Schools reported that during the first two years of this program, educational outcomes were
increased and health outcomes were improved.
Students assessed by school nurses:
2012/13: 5,401
2013/14: 32,284
2014/15: 34,949
Attendance:
2013/14: .024 increase in attendance
2014/15: .037 decrease in attendance
Fluoride varnish:
60 students received fluoride varnish during the 2014/15 school year.
Fluoride varnish is a protective coating painted on a child’s teeth to help prevent
cavities.
Children screened for obesity:
76.1% increase in BMI screenings from previous year
Increase in children with an identified health care home:
2013/14: a baseline was established
2014/15: 6% increase (557 students) in the number of children having a
primary health care provider
Breathe Easy (asthma screening program):
Screenings at 8 schools
112 identified with abnormal lung function
This program provides free asthma screenings, assessments, asthma education and follow-up
phone calls to event participants. Goals are reached through a team approach comprised of
physicians, nurse practitioners, nurses, respiratory therapists, student nurses and community
volunteers. Screenings are provided for children 5 years or older, and in addition, some adult
screenings are performed, particularly at community venues.
From June 2013 to July 2015, the Breathe Easy team conducted 20 events, screened 1,526
individuals and identified 155 participants as having a significantly abnormal screening.
Identifying such a large number of children and adults with increased risk for asthma further
supports the utilization of this program in Knoxville and the surrounding communities.

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Methodology and process for 2016 CHNA
Planning
The planning process for the 2016 CHNA began in December 2014. An internal team was formed
to identify and approve resources and timelines for conducting the necessary steps for formation
of the needs assessment.
A schedule was established to allow sufficient time and resources to indentify and engage
community partners in key informant interviews and focus groups. The internal team used
a modified version of the Mobilizing for Action through Planning and Partnerships (MAPP)
process. This process is commonly used to assist community health organizations during the
needs assessment process. The MAPP process provided the framework for Children’s Hospital to
organize, visualize, assess, strategize, formulate goals and take action.
Gathering and analyzing information
Key informant interview
Key informants were identified in five counties (see Appendix A) and by using the following
criteria.
1. Those with special knowledge of or expertise in public health;
2. At least one state, local, tribal, or regional government public health department
(or equivalent department or agency) or State Office of Rural Health with knowledge,
information, or expertise relevant to the health needs of that community;
3. Members of medically underserved, low-income, and minority populations in the
community served by the hospital facility, or individual or organizations serving or
representing the interest of such populations;
4. Members of medically underserved populations include populations experiencing
health disparities or at risk of not receiving adequate medical care as a result of being
uninsured or underinsured or due to geographic, language, financial or other barriers.
Each interviewer was contacted using a uniform script (Appendix B). These face-to-face
interviews were conducted by Children’s Hospital Community Benefit staff at scheduled times.
Summary findings of the key informant interviews can be found in Appendix C.
Focus Groups
Children’s Hospital conducted five focus groups, enlisting the service of expert facilitators. The
demographics and findings of this process are included in Appendix D. The groups identified
meeting specific criteria were:

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1. Children’s Hospital’s Family Advisory Council
2. Emerald Youth Foundation Parent Group
3. Children’s Hospital’s Board of Directors
4. Primary care physicians
5. Knox County school nurses
Community survey
A survey for the general population was created to gain input from community residents and
key stakeholders about the top health needs and priorities of children. We promoted the survey
on the Children’s Hospital website and social media to encourage people to complete an online,
confidential survey (Appendix E). Results are indicated in Appendix E.
Primary data summary
The gathering and analyzing phase of the CHNA includes interviewing key informants,
conducting focus groups and collecting information through an online survey.
During the key informant interviews, feedback was sought on the perceived health needs of
children in our community. Childhood obesity, access to care, wellness and injury prevention,
mental health, dental care, asthma and allergies ranked the highest for seriousness and potential
needs to be addressed.
The five focus group sessions revealed detailed and knowledgeable conversations regarding
identifying the most critical needs of children in our community. The groups indicated access
to care, childhood obesity, outpatient mental health, parental substance abuse, neonatal
abstinence syndrome and injury prevention were needs that need to be addressed. A
comprehensive report and summary are available upon request by utilizing the contact
information available on page 13.
Summary results of the online survey indicate the largest health care issues in our area including
parental substance abuse, obesity, allergies and asthma, smoking and access to primary care.
Other issues indicated were behavioral health, health education, dental care and teen pregnancy.
Secondary data summary
In addition to engaging community members and soliciting information , Children’s Hospital
also reviewed and compiled qualitative data to explore core health indicators in effort to
recognize the current needs of our community. Sources used included the Knox County Health
Department Community Health Needs Assessment; County Health Rankings 2015; Tennessee,
Robert Wood Johnson Foundation; 2013/2014 State and County QuickFacts, U.S. Census Bureau;
and Kidscount Data Center 2014 Tennessee Commission on Children and Youth.
See Appendix F for 2014 Key Statistics.

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Findings and conclusions
Identifying health needs
Children’s Hospital analyzed all of the quantitative and qualitative data described above
and in the appendices hereafter. In general, the input received from community members
and those who participate more in the delivery of health care services varied slightly. The
health needs identified through the information process are indicated in Appendix C: Key
informant interview summary, Appendix D: Focus group listing and findings and Appendix E:
Community survey and summary.
Selecting priorities for guidance with the implementation strategy
The purpose of an implementation plan is to identify the activities and responsible parties
required to work toward making a positive impact towards improving the health needs of
children in our communities. This allows for proper allocation of staff and financial resources.
Children’s Hospital developed the implementation strategy based on the findings of the
current assessment on rankings of health needs from primary and secondary data in
conjunction with identifying other resources available in the community. These collaborative
efforts help key partners stay focused on critical issues working towards healthy futures for
our children.
Gathering, tracking and reporting community benefit efforts
The Children’s Hospital Community Benefits Department provides oversight for more than
30 reporters who gather, track and record occurrences in the tracking and reporting program
called CBISA from Lyon Software.
Current resources (Appendix G)

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Implementation strategy 2016
The needs assessment process allows Children’s Hospital to identify the pediatric health care
needs in our region and direct our commitment to providing resources to help positively
impact child health. In addition to the many valuable, innovative programs and services
available at Children’s Hospital, there are five specific areas that will have a defined focus. In
May 2016, the Children’s Hospital Board of Directors unanimously approved the prioritized
focus areas described below to be the foundation of our implementation strategy.
Neonatal Abstinence Syndrome
Tennessee has seen dramatic growth in the number of newborns with Neonatal Abstinence
Syndrome (NAS). In 1999, less than 100 children were diagnosed with NAS according to the
Tennessee Department of Health. By 2010, more than 500 cases were reported, and in 2015,
the number of NAS births in Tennessee had risen to 986 with 32.7 percent (323 babies) being
treated at Children’s Hospital. Since 2010, the hospital has treated 1,354 infants with NAS.
Situated at the center of this epidemic, Children’s Hospital is a leader in establishing treatment
protocols of patients with NAS and in the training of their caregivers. However, there is a
gap in tracking, support and follow up for a significant number of these infants and their
caregivers after discharge. While some receive the support and care they need, others are lost
to follow up.
Children’s Hospital plans to research and develop a formal NAS care coordination service.
This strategy includes data collection, research and travel to established NAS programs across
the country. We plan to explore further collaborations that may include additional support.
Children’s Hospital embraces the broader scope of providing care coordination for patients
with NAS and is committed to supporting the service’s sustainability and expansion through
current operations and philanthropic support. Children’s Hospital has a long history of
successful fundraising. As the NAS care coordination service expands, it would be a priority for
philanthropic support.
Children’s Hospital’s goals for the first phase of program development include:
• Conducting two to three visits to NAS programs to evaluate best follow-up practices
• Developing collaborative partnerships with other programs working with NAS patient
families
• Researching former patients with a history of NAS to identify services being used after
discharge
• Developing a business plan for creating an NAS care coordination service. The business
plan developed during the first phase will be used to guide the implementation of the
NAS care coordination service in the second phase.

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The measurable impact will be demonstrated through:
• Identification and/or development of best practice models to assist children who were
born with NAS.
• Identification and engagement of community partners to ensure coordination of care
and family support
• Improved care efficiency for the child and increased family satisfaction with the care
provided
Project ADAM Tennessee
Project ADAM Tennessee provides schools with information, materials, training and support in
the management of Public Access to Defibrillation (PAD) programs. Supported by Children’s
Hospital since 2011, the placement of Automated External Defibrillators (AEDs) in area
schools is a priority. In addition to these life-saving devices, Project ADAM helps schools
coordinate and train emergency response teams, assist with practice drills and ensure staff
and community awareness.
Recent state legislation requires annual awareness training and practice drills for all schools in
Tennessee. In addition, the law requires coaches, athletes and parents/guardians of athletes
to be informed about the warning signs of sudden cardiac arrest and proper responses.
Schools must have emergency response plans in place, identify response teams trained
in CPR and perform CPR/AED drills when students are present. The law passed in 2016
recommending Project ADAM Tennessee as a resource for schools has created a dialogue
with school nurses and school health coordinators across the state that will continue to drive
the development of effective ways to provide materials, training and support to schools.
These new requirements will not only strengthen community responses to sudden cardiac
arrest, they will improve awareness about the importance of CPR and AED training and will
ultimately help Tennesseans have the best possible chance of surviving sudden cardiac arrest.
As AEDs become aged and as new school facilities are constructed, we will continue to
encourage schools to be properly equipped. We will focus on providing awareness training
for schools with our presence, consultation and materials. When possible, we will travel
to schools to personally demonstrate efficient and effective training and review individual
or system programs. For those outside our service area, we’ll continue to be available for
consultation and to develop accessible training materials. We continue to help evaluate AED
needs and help provide support where appropriate.
Project ADAM Tennessee continues to look for ways to expand our reach across the state and
country. We are currently in the process of assisting other hospitals across Tennessee with
implementation of a version of this program.

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Injury Prevention
According to the Centers for Disease Control and Prevention, accidental injury is the number
one cause of death among children ages 14 and under in the United States. Each year, one of
every four children requires medical attention for an accidental injury, and up to 90 percent of
these injuries can be prevented through education.
The Children’s Hospital’s injury prevention programs play a vital role in our community. These
programs are constantly evolving and include topics such as falls, water safety, fire safety and
child sleep safety.
Two valuable programs to our community are the Safe Travels program and our bike safety
program. The Safe Travels program is a child passenger safety program that focuses on
partnering with local agencies to conduct car seat inspections and to replace unsafe seats.
Our bike safety program is offered to local schools and at community events to encourage
the proper use of bike helmets. Helmets are many times provided at no cost to participants.
This program focuses on the ways to keep children safe while riding bikes or other wheeled
sports. The primary goal of the program is to reduce the occurrence of unintentional pediatric
injuries using evidence-based prevention techniques developed by Safe Kids Worldwide and
other proven injury prevention experts.
Children’s Hospital is a Comprehensive Regional Pediatric Center. We provide pediatric
education, training and networking services for pre-hospital professionals, hospitals and
health care providers in our designated region. We are committed to continuing these
programs to help keep children in our community safe.
Childhood Obesity
The Childhood Obesity Coalition’s vision is increase the health of the citizens in our area
and to help Knoxville become one of America’s fittest cities. According to the 2014-2015
Community Health Assessment, 17.4 percent of Knox County students were measured as
obese in the 2013-2014 school year. Programs are designed to prevent childhood obesity by
including both nutrition education and physical activity components. The overall goal for
obesity prevention programs is for children to develop and improve their social, physical,
emotional, cognitive and interactive skills to improve their health outcomes. Additionally, to
continue to improve the community, the coalition plans to actively show support for public
policy and advocacy around nutrition, increased physical activity and to build a community
where people are more active.

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Allergies and asthma
According to the World Health Organization, asthma is the most common childhood pediatric
disease. Knoxville has been consistently identified as one of the top 10 metropolitan areas in
the country where it is most challenging to live with asthma. As a key pediatric provider in
East Tennessee, one of our strategic goals is to create a virtual center for the care of a child with
asthma in our community.
For each child with asthma, we work towards providing the child and the caregiver the
most comprehensive care coordination of the disease process including education for self
management, proper medication regimen and follow-up care. We will continue to work with
primary care doctors to ensure they have the knowledge and resources to provide excellent“well
care”for children with asthma.
Our goals include:
• Providing access to appropriate and timely utilization of our asthma specialist
• Maximization of partnerships between school nurses and the health care providers
• Providing education on eliminating environmental triggers
• A focus on creating a best practice care map for patients who present to the Children’s
Hospital Emergency Department which will guide them through the inpatient setting to
discharge
• Form strategic alliances with asthma experts in the community and across the state to
improve and standardize care
• Continue to refine an asthma call process so that children with moderate to severe
persistent asthma or those that do not have a primary care provider can have access
to high quality follow-up care within 72 hours of presentation to the Children’s Hospital
Emergency Department. Key stakeholder relationships play an important role in the
success of this process
• Continue to collaborate with Children’s Hospital Alliance of Tennessee (CHAT) to
standardize and will be implement best practice asthma education
• Through our Breathe Easy program, perform screenings in high-risk schools and make
recommendations for follow-up and self care
• Work with our key stakeholders and the University of Tennessee at Knoxville to consider
novel ways to improve self management and potentially provide better school support
and/or care coordination
With our asthma experts and key stakeholders, we want to create or provide access to primary
care providers to the resources needed to provide excellent asthma well care. For the children
most at risk, we have set goals to pursue the viability of providing better community, school and
home support for these children.

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Community needs not addressed
Additional topic areas were identified during the CHNA process including teen pregnancy,
teen substance abuse, parental substance abuse and dental care. While Children’s Hospital
will continue to focus on the majority of efforts outlined in our implementation strategy, all
needs identified will be reviewed for future consideration and collaboration. These areas,
while still important to the health of children in the community, will be met through other
health care organizations with assistance from Children’s Hospital as needed. The community
needs not addressed by Children’s Hospital will continue to be addressed by governmental
agencies and existing community-based organizations.
Request for more information, written comments solicited
In addition to this CHNA being publicly available on our website, other reports relevant to this
process can be made available by request to:
East Tennessee Children’s Hospital
Community Benefits Department
2018 Clinch Avenue
Knoxville, TN 37916
Phone: 865-541-8532
Email: lcoxcollier@etch.com
Children’s Hospital solicits written comments on each CHNA. This is indicated on the
Children’s Hospital website at https://www.etch.com/community/chna/. As of 1-8-2016, there
have been no written comments regarding the 2013 CHNA.

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County Name Title Organization
Anderson VickiViolette, P.h.D. Director of Schools Clinton City Schools
Jamie Jordan Coordinator Clinton City Schools
Art Miller Director Anderson County Health Department
Anna Hurt Director, Anderson County Schools
Coordinated School Health
Rick Meredith President Anderson County Chamber
of Commerce
Blount Heather Ledbetter Coordinated School Health Coordinator Maryville City Schools
Kelly Gallemore Coordinated School Health Coordinator Alcoa City Schools
Mary Beth Blevins Coordinated School Health Coordinator Blount County Schools
Kelly Roberts Director Family Resource Center
Jane Andrews Director Blount Memorial Foundation
& Community Outreach
Tabitha Damron Executive Director New Hope Children’s Advocacy Center
Jefferson Sue McBee, R.N. Associate Professor Carson Newman University
MichelleWeatherbee, R.N. Nurse Jefferson County Health Department
Ronda Click Coordinated School Health Coordinator Jefferson County
Knox Tim Irwin Judge Knox County Juvenile Court
Kathy Brown Associate Professor University ofTennessee Department
and MPH Program Director of Public Health
LisaWagoner Coordinated School Knox County Schools
Health Coordinator
Nan Gaylord, P.h.D., Associate Professor, Vine Street School Health Center
P.N.P., R.N. University ofTennessee
Marcus Jackson Director Boys and Girls Club
Steve Diggs Director EmeraldYouth Foundation
Mark Field Vice President of Membership Knoxville Chamber Partnership
Elaine Streno Executive Director Second Harvest
Charlayne Frazier TENNderCARE Program Manager Knox County Health Department
Juanita Boring, R.N. Nurse Richard Bean Juvenile Detention Center
Ryan Redman, M.D. Director of Emergency Services EastTennessee Children’s Hospital
Lise Christensen, M.D. Chief of Medical Staff EastTennessee Children’s Hospital
Joe Childs, M.D. Vice President for Medical Services EastTennessee Children’s Hospital
Martha Buchanan, M.D. Director and Public Health Officer Knox County Health Department
Sevier Don Best Coordinated School Health Coordinator Sevier County Schools
Jana Chambers Director Sevier County Health Department
Garnet Southerland Wellness and Community Health Supervisor LeConte Medical Center
MaryVance Director Mountain Good Hope Sheppard
Linda Hyder Extension Agent University ofTennessee Extension
Appendix A: Key informants identified

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Appendix B: Key informant interview uniform script
Key informants will be interviewed as part of the Children’s Hospital qualitative data collection
process. These informants will represent a variety of governmental, social, and religious
organizations within five key counties in the Children’s Hospital service area. We want to
acknowledge all of the informants for their participation; however, all informants will not be
identified in order to protect confidentiality. In order to meet IRS requirements, we will ask
informants to agree to be identified as informants who meet some of the criteria as required
by the IRS:
1. Those with special knowledge of or expertise in public health;
2. At least one state, local, tribal, or regional government public health department
(or equivalent department or agency) or State Office of Rural Health with
knowledge, information, or expertise relevant to the health needs of that
community;
3. Members of medically underserved, low-income, and minority populations in
the community served by the hospital facility, or individual or organizations serving
or representing the interest of such populations;
4. Members of medically underserved populations include populations experiencing
health disparities or at risk of not receiving adequate medical care as a result of
being uninsured or underinsured or due to geographic, language, financial or other
barriers.
Hello, may I please speak with [NAME]?
My name is [INTERVIEWER’S NAME] and I am calling from East Tennessee Children’s Hospital.
________ from __________ gave me your information in order to participate in the 2016
Children’s Hospital Community Health Needs Assessment.
The purpose of this assessment is for the hospital to gain an understanding of the current
health status of their target area, learn about the top health needs and priorities, and to
develop an action plan to address some of those health needs when possible. Part of the
assessment is gathering quantitative data on health indicators from secondary analysis and
the other part of the assessment process includes getting input from community residents
and key stakeholders, which is why I am calling to ask to meet with you for a brief interview.
Your input will be used to inform the health needs assessment and potential future action by
Children’s Hospital in our community.
The interview will take 30 minutes to one hour. Can we schedule a meeting in the next week or
two?

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Needs identified Number of responses
Access to care (Cost, availability and transportation..................................................................................21
Asthma/allergies......................................................................................................................................................14
Childhood obesity/nutrition/physical activity.............................................................................................24
Clinical preventive services/wellness initiatives/injury and violence..................................................18
Dental care.................................................................................................................................................................15
Education health literacy........................................................................................................................................3
Neonatal abstinence syndrome.........................................................................................................................13
Outpatient mental health/autism spectrum/behavioral disorders......................................................24
Parent education.......................................................................................................................................................8
Parental substance abuse (alcohol and drug)...............................................................................................11
Pediatric inpatient psychiatric health................................................................................................................0
Teen pregnancy and sexually transmitted diseases.....................................................................................2
Tobacco/alcohol/drug abuse (children and adolescents)..........................................................................5
Type 1 diabetes..........................................................................................................................................................2
Quotes from interviews
On parenting:
“I think schools do a fantastic job, but there’s a limit to what you’re capable of doing, so I
think it’s empowering and educating parents to help their kids make better choices and
consequently help them make better choices.”
On transportation pertaining to specialty clinics for obesity/behavioral health:
“You can offer the best service in the world, but if it’s hard to get to it or it takes a great deal of
effort, if there’s a lot of transportation involved, especially for the economically disadvantaged
group, then they probably won’t go. … transportation is a barrier to accessing health services
for our economically disadvantaged families.”
On nutrition and obesity:
“I think Children’s Hospital can support parks and activities and school recreational programs,
and I think some of the nutrition programs through school that Second Harvest and others do
to try to – food that kids are actually taking home and having access to that’s healthy. …I think
just promoting ways for kids to be active. …I like trying to work through the schools. I think
there are a lot of resources for before school starts, but I think that the schools need our help,
school-age kids need our help.”
Appendix C: Key informant interview summary

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On mental health and psych patients:
“Number one, we need to have increased funding from the state. …The state absolutely has
to reimburse for psychiatric care, and we don’t have any child psychiatrists on staff, but we
have one, so they obviously are not getting reimbursed, so we have to find a way to reimburse
child psychiatrists so they’d be willing to be on our staff. …Second is do we need to add child
psychiatric services to our hospital or find a way to provide that kind of care? …Maybe going
back to the local leaders and asking how we can better serve this population of kids, because
it’s just a travesty for these families that these kids are in our ER for two to three days.”
On mental health, injury prevention and trauma:
“Give us more funding. …We just see a continued need within our community to continue to
educate people on (injury prevention).”
On meeting needs for preventative care and mental health:
“We have all these services that are available, but there’s a disconnect between the service
and getting it to the people in a relational way. …So I would just respond I think we need
more organizations, whether that be the church or other groups, that can engage relationally
with the families and make the connection to the services that are available, sort of reconcile
all of that.”
On preventative services and mental health:
“Essentially, it’s just going to take a lot of resources. The problem with the primary care issue
is there’s just not enough primary care docs out there, where they can keep a reasonable
number of patients. …And then the psychiatric stuff is just going to take resources, and I don’t
know where that comes from. …We have a lot of resources here in this community, but that’s
one we just don’t have.”

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Appendix D: Focus group summary listing and findings
Children’s Hospital conducted five focus groups, enlisting the service of expert facilitators. The
demographics and findings of this process are included in Appendix D. The groups identified
meeting specific criteria were:
1. Children’s Hospital Family Advisory Council
2. Emerald Youth Foundation parent group
3. Children’s Hospital Board of Directors
4. Primary care physicians
5. Knox County school nurses
The five focus group sessions revealed detailed conversations between experts regarding
identifying the most critical needs of children in our community. In summary, the groups
indicated access to care, childhood obesity, outpatient mental health, parental substance
abuse, neonatal abstinence syndrome and injury prevention were needs that need to be
addressed. A comprehensive report and summary are available upon request by utilizing the
contact information available on page 13.

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Appendix E: Community survey and summary
East Tennessee Children’s Hospital wants to be sure that we are meeting the health care needs
of all children in our community. Please fill out this short survey to help us identify areas in
which we can better serve you.
What are the ages of the children in your home? *
Do you have difficulty finding healthcare for your child? * o Yes o No
Does your child have a chronic health care condition? * o Yes o No
If yes, what is the diagnosis?
Does your child have a primary care doctor? * o Yes o No
If yes, how often does your child see this doctor? Once a month or less?
More than once a month?
How would you rate your child’s Health? *
o Excellent o Good o Fair o Poor o Very Poor
Which health care issue (s) listed below do you feel are the largest problems in our area
(check all that apply)? *
o Access to Primary Care o Allergies and Asthma o Behavioral Health o Dental Care
o Diabetes o Diversity o Handicapped Access o Health Education in Schools
o Illegal Drug Use, Parental Illegal Drug Use o Child Immunizations o Injury Prevention
o Obesity o Parenting/Parent Education o Smoking o Teen Pregnancy
How often does your child go to a hospital emergency room? *
o Rarely o Once a month or less o At least twice a month
Does your child’s school nurse help meet the healthcare needs of your child? *
o Yes o No
What is your ethnicity? *
o African-American o American Indian or Alaska Native o Asian o Caucasian
o Hispanic Two or more races o Other___________________________________________

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Summary of survey results
Does your child have a primary care doctor?
Yes – 26 No – 2
Which health care issue(s) listed below do you feel are the largest problems in our area?
Please let us know any additional thoughts, ideas or concerns you may have about healthcare
needs and issues in our community.
Issue
Access to primary care
Allergies and asthma
Behavioral health
Diabetes
Illegal drug use, child
Illegal drug use, parental
Immunizations
Injury prevention
Obesity
Parenting/parent education
Smoking
Teen pregnancy
Dental care
Health education in schools
Handicapped access
Diversity
Number of responses
8
14
10
6
9
15
3
3
15
12
13
7
5
7
2
1
What is your ZIP code? *
What kind of insurance do you have for your child? *
o Commercial o Cover Kids o TENNcare o No Insurance
o Other ______________________________________________
Please let us know any additional thoughts, ideas or concerns you may have about
healthcare needs and issues in our community.

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Appendix F: 2014 Key statistics
Community health needs assessment
East Tennessee Children’s Hospital
for the fiscal year ending June 30, 2015
2014 Key Statistics1
Knox Blount Sevier Jefferson Anderson TN U.S.
Demographics
Population 448,644 126,339 95,110 52,677 75,528 6,549,352 0
% below 18 years of age 21.5% 21.4% 21.4% 21.1% 21.1% 23.0% 23.3%
HealthOutcomesRank2
15 8 22 51 41
Mortality
Infant mortality 32 10 3 5 5 562
Child mortality 16 4 2 0 5 217
Morbidity
Low Birthweight 8.8% 8.5% 8.9% 7.6% 9.1% 9.2%
HealthBehaviors
Teen births 34 42 55 47 43 47
Physical Inactivity 28% 32% 32% 33% 32% 30%
Adult Smoking 19% 21% 28% 26% 21% 23%
Healthcare
Unisured 15% 15% 22% 17% 14%
Social&EconomicFactors
Children in poverty 23.0% 21.8% 26.5% 25.6% 23.8% 25.9%
Children in single-parent households 29% 27% 31% 35% 33% 36%
Children participating in
free/reduced lunch
PhysicalEnvironment
Access to recreational facilities 78% 71% 82% 63% 76% 70%
Access to healthy foods 6.9 7.4 7.5 7.5 7.4
1
Sources: County Health Rankings 2015;Tennessee, RobertWood Johnson Foundation; 2013/2014 State and County QuickFacts, U.S. Census
Bureau; Kidscount Data Center 2014Tennessee Commission on Children andYouth.
2
The 2015 County Health Rankings reports ranksTennessee counties according to their summary measure of health outcomes and health
factors. Counties also receive a rank for mortality, morbidity, health behaviors, clinical care, social and economic factors and physical
environment. Access to healthy foods 1-10 scale where 10 is the best.

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Anderson County
• Allies for Substance Abuse Prevention (ASAP)
• Anderson County Coalition
• Civitan Club
• Clinton Drug Store
• Clinton Fire Department
• Clinton Lions Club
• Clinton Police Department
• Department of Health
• East Tennessee Children’s Hospital
• Health Advisory Council
• Helen Ross McNabb
• Local churches
• Optimist Club
• Rotary Club
• Second Harvest Food Bank
• State Department of Health
• University of Tennessee Agriculture Extension
• University of Tennessee Extension Program
• University of Tennessee Nursing
Blount County
• Blount County Chamber
• Blount County Community Health Initiative
– Blount Benefits
– Food Allergy Action Team (FACET)
– Mental Health Awareness and Suicide
Prevention Alliance (MHASPA)
– Safe Blount County
– Substance Abuse Prevention Group
– Teen Pregnancy Prevention
• Blount County School System
– Project Adam
– Safe Kids
• Fire Department
• Blount County Health Department
• New Hope Advocacy Center
• Police Department
• United Way
Jefferson County
• Boys and Girls Club
• Coordinated School Health
• Second Harvest
• Local churches
• Jefferson County Health Council
Knox County
Big Brothers Big Sisters
• Boys and Girls Club
• Catholic Charities
• Cherokee Health Systems
• City of Knoxville Parks and Recreation
• Columbus Home
• Community Action Committee (CAC)
• Compassion Coalition
• Department of Children’s Services
– Obesity Coalition
– Project Adam
• EmeraldYouth Foundation
• Emergency Shelters
• Fellowship of Christian Athletes
• Helen Ross McNabb
• Knox Area Rescue Ministries (KARM)
• Knox County Health Department
• Knox County Schools
• Leadership Knoxville
• Local Donors
• Mobile Crisis Unit
• Omni Vision
• Peninsula
• Public Health
• Salvation Army
• Second Harvest
• Smoky Mountain Children’s Home
• University of Tennessee College of Nursing
• Vine Health Center
• YMCA
• Youth Villages
Sevier County
• Cherokee Health Systems
• Community groups
• East Tennessee State University third-year
medical students
• HEAL and MOMS
• Sevier County Health Department
• Sevier County Health Improvement Council
• Sevier County Promise
• Sevier County school nurses
Appendix G: Current community resources

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