Toole County,
Montana
Frontier Medicine Better Health Partnership
Community Health Needs Assessment Report
Survey conducted by
Marias Medical Center
Shelby, Montana
In cooperation with
The Montana Office of Rural Health &
The National Rural Health Resource Center
July 2014
Marias Medical Center
Community Health Needs Assessment
Table of Contents
I. Introduction ............................................................................................................................................. 2
II. Health Assessment Process .................................................................................................................... 2
III. Survey Methodology............................................................................................................................. 2
IV. Survey Respondent Demographics ....................................................................................................... 4
V. Survey Findings ..................................................................................................................................... 8
VI. Focus Group Methodology ................................................................................................................. 45
VII. Focus Group Findings ....................................................................................................................... 46
VIII. Summary .......................................................................................................................................... 48
Appendix A – Steering Committee Members ........................................................................................... 49
Appendix B – Public Health and Populations Consultation ..................................................................... 50
Appendix C – Survey Cover Letter .......................................................................................................... 52
Appendix D – Survey Instrument ............................................................................................................. 53
Appendix E – Responses to Other and Comments ................................................................................... 59
Appendix F – Focus Group Questions ...................................................................................................... 63
Appendix G – Focus Group Notes ............................................................................................................ 64
Appendix H – Secondary Data ................................................................................................................. 81
1
Marias Medical Center
Community Survey & Focus Groups
Summary Report
July 2014
I. Introduction
Marias Medical Center (MMC) is a 25-bed Critical Access Hospital in Shelby, MT with a
service area of just over 1,900 square miles serving the Toole County population of roughly
5,324 people. Other health services available include the Marias Care Center, a 63-bed nursing
home, and Marias Heritage Center, a licensed 40-unit retirement and assisted living facility. In
addition, Marias Healthcare Services, Inc., a Federally Qualified Health Center (FQHC) clinic
look-a-like, is a community partner located on MMC’s campus. MMC participated in the
Community Health Services Development (CHSD) process, a Community Health Needs
Assessment (CHNA), conducted by the Montana Office of Rural Health and the National Rural
Health Resource Center in Duluth, Minnesota. The CHNA was funded by the Frontier Medicine
Better Health Partnership (FMBHP) Project. Community involvement in steering committee
meetings and focus groups enhanced the community’s engagement in the assessment process.
In the spring of 2014, Marias Medical Center’s service area was surveyed about its healthcare
system. This report shows the results of the survey in both narrative and chart formats. A copy
of the survey instrument is included at the end of this report (Appendix D). Readers are invited to
familiarize themselves with the survey instrument and the subsequent findings. The narrative
report touches on the highlights while the charts present data for virtually every question asked.
Please note: we are able to compare some of the 2014 survey data with data from previous
surveys conducted in 2009. If any statistical significance exists, it will be reported. The
significance level was set at 0.05.
II. Health Assessment Process
A Steering Committee was convened to assist Marias Medical Center in conducting the CHSD
assessment process. A diverse group of community members representing various organizations
and populations within the community (ex. public health, elderly, uninsured) came together in
January 2014. For a list of all Steering Committee members and their affiliations, see Appendix
A. The Steering Committee met twice during the CHSD process; first to discuss health concerns
in the community and offer their perspective in designing the survey instrument and again to
review results of the survey and focus groups.
III. Survey Methodology
Survey Instrument
In April 2014, surveys were mailed out to the residents in Marias Medical Center’s service area.
The survey was based on a design that has been used extensively in the states of Washington,
Wyoming, Alaska, Montana, and Idaho. The survey was designed to provide each facility with
information from local residents regarding:
 Demographics of respondents
 Hospitals, primary care providers, and specialists used plus reasons for selection
 Local healthcare provider usage
 Services preferred locally
 Perception and satisfaction of local healthcare
2
Sampling
Marias Medical Center provided the National Rural Health Resource Center with a list of
outpatient and inpatient admissions. Those zip codes with the greatest number of admissions
were selected to be included in the survey. A random list of 800 residents was then selected
from Prime Net Data Source. Residence was stratified in the initial sample selection so that each
area would be represented in proportion to the overall served population and the proportion of
past admissions. (Note: although the survey samples were proportionately selected, actual
surveys returned from each population area varied which may result in slightly less proportional
results.)
Additionally, three focus groups were held to identify the motives of local residents when
selecting healthcare providers and to discover reasons why people may leave the Shelby area to
seek healthcare services. It was intended that this research would help determine the awareness
of local programs and services, as well as the level of satisfaction with local services, providers,
and facilities.
Information Gaps: Data
It is a difficult task to define the health of rural and frontier communities in Montana due to the
large geographic size, economic and environmental diversity, and low population density.
Obtaining reliable, localized health status indicators for rural communities continues to be a
challenge in Montana.
There are many standard health indices used to rank and monitor health in an urban setting that
do not translate as accurately in rural and frontier areas. In the absence of sufficient health
indices for rural and frontier communities in Montana, utilizing what is available is done with an
understanding of access to care in rural and frontier Montana communities and barriers of
disease surveillance in this setting.
The low population density of rural and frontier communities require regional reporting of many
major health indices including chronic disease burden and behavior health indices. The Montana
BRFSS [Behavioral Risk Factor Surveillance System], through a cooperative agreement with the
Center for Disease Control (CDC), is used to identify regional trends in health-related behaviors.
The fact that many health indices for rural and frontier counties are reported regionally makes it
impossible to set the target population aside from the five more-developed Montana counties.
Information Gaps: Limitations in Survey Methodology
A common approach to survey research is the mailed survey. However, this approach is not
without limitations. There is always the concern of non-response as it may affect the
representativeness of the sample, thus a mixture of different data collection methodologies is
recommended. Conducting community focus groups and key informant interviews in addition to
the random sample survey allows for a more robust sample and, ultimately, these efforts help to
increase the community response rate. Partnering with local community organizations such as
public health, community health centers, and senior centers, just to name a few, helps to reach
segments of the population that might not otherwise respond to a survey or attend a focus group.
3
Survey Implementation
In April 2014, the community health services survey, a cover letter from the National Rural
Health Resource Center with Marias Medical Center’s Chief Executive Officer’s signature on
Marias Medical Center letterhead, and a postage paid reply envelope were mailed to 800
randomly selected residents in the hospital’s service area. A news release was sent to local
newspapers prior to the survey distribution announcing that Marias Medical Center would be
conducting a community health services survey throughout the region in cooperation with the
Montana Office of Rural Health.
One hundred eighty-five surveys were returned out of 800. Of those 800 surveys, 61 were
returned undeliverable for a 25% response rate. From this point on, the total number of surveys
will be out of 739. Based upon the sample size, we can be 95% confident that the responses to
the survey questions are representative of the service area population, plus or minus 6.27%.
IV. Survey Respondent Demographics
A total of 739 surveys were distributed amongst Marias Medical Center’s service area. One
hundred eighty-five were completed for a 25% response rate. The following tables indicate the
demographic characteristics of the survey respondents. Information on location, gender, age, and
employment is included. Percentages indicated on the tables and graphs are based upon the total
number of responses for each individual question, as some respondents did not answer all
questions.
.
Place of Residence (Question 31)
While there are some large differences in the percentages below, the absolute differences are
small. The returned surveys are skewed toward the Shelby population which is reasonable given
that this is where most of the services are located.
Area
Shelby1
Sunburst
Valier
Cut Bank
Kevin
Oilmont
Chester
Conrad
Galata
Sweet Grass
Browning
Other
TOTAL
1
Zip code
59474
59482
59486
59427
59454
59466
59522
59425
59444
59484
59417
2009
Count
Percent
121
58.1%
31
14.9%
10
4.8%
11
5.3%
6
2.9%
1
0.5%
2
1.0%
5
2.4%
8
3.8%
7
3.4%
1
0.5%
5
2.4%
208
100%
Significantly more respondents were from Shelby in 2014 than in 2009.
4
2014
Count
Percent
135
75.0%
17
9.4%
13
7.2%
7
3.9%
3
1.7%
2
1.0%
1
0.6%
1
0.6%
1
0.6%
0
0
Not Asked in 2014
0
0
180
100%
Gender (Question 32)
2014 N= 185
2009 N= 216
Of the 185 surveys returned, 69.8% (n=129) of survey respondents were female, 27% (n=50)
were male, and 3.2% (n=6) chose not to answer this question. The survey was distributed to a
random sample consisting of 50% women and 50% men. It is not unusual for survey
respondents to be predominantly female, particularly when the survey is healthcare-oriented
since women are frequently the healthcare decision makers for families.
5
Age of Respondents (Question 33)
2014 N= 181
2009 N= 206
Thirty-two percent of respondents (n=57) were between the ages of 56-65. Eighteen percent of
respondents (n=33) were between the ages of 66-75 and 15.5% of respondents (n=28) were
between the ages of 46-55. This statistic is comparable to other Critical Access Hospital (CAH)
demographics. The increasing percentage of aging residents in rural communities is a trend
which is seen throughout Montana and will likely have a significant impact on the need for
healthcare services during the next 10-20 years. However, it is important to note that the survey
was targeted to adults and therefore, no respondents are under age 18. Older residents are also
more invested in healthcare decision making and therefore, are more likely to respond to
healthcare surveys, as reflected by this graph.
6
Employment Status (Question 34)
2014 N= 177
2009 N= 195
Forty-eight percent (n=85) of respondents reported working full time while 31.1% (n=55) are
retired. Eleven percent of respondents (n=20) indicated they work part time. Respondents could
select all that apply so percentages do not equal 100%. Eight respondents chose not to answer
this question.
7
V. Survey Findings – Community Health
Impression of Community (Question 1)
2014 N= 173
2009 N= 208
Respondents were asked to indicate how they would rate the general health of their community.
Fifty-five percent of respondents (n=95) rated their community as “Somewhat healthy.” Thirtyfive percent of respondents (n=61) felt their community was “Healthy” and 8.7% (n=15) felt
their community was “Unhealthy.” No respondents felt their community was “Very healthy” and
twelve respondents chose not to respond to this question.
1
Significantly fewer respondents rated their community as very healthy or healthy in 2014 than in 2009.
8
Health Concerns for Community (Question 2)
2014 N= 185
2009 N= 218
Respondents were asked what they felt the three most serious health concerns were in their
community. The number one health concern identified by respondents was “Alcohol abuse/
substance abuse” at 51.9% (n=96). “Obesity/poor nutrition” was also a high priority at 33%
(n=61) then “Cancer” at 31.4% (n=58). Respondents were asked to pick their top three serious
health concerns so percentages do not equal 100%.
Health Concern
Alcohol abuse/substance abuse
Obesity/poor nutrition
Cancer
Illegal drug abuse
Diabetes
Heart disease
Lack of exercise
Tobacco use
Depression/anxiety1
Lack of access to healthcare
Mental health issues
Prescription drug abuse
Child abuse/neglect
Accidents/injuries
Motor vehicle accidents
Domestic violence
Lack of dental care
Stroke
Other
2009
Count
Percent
105
48.2%
58
26.6%
85
39.0%
Not asked in 2009
44
20.2%
47
21.6%
45
20.6%
35
16.1%
44
20.2%
21
9.6%
18
8.3%
Not asked in 2009
26
11.9%
Not asked in 2009
11
5.0%
12
5.5%
14
6.4%
13
6.0%
4
1.8%
1
2014
Count
96
61
58
46
36
30
28
27
23
23
21
21
18
17
9
5
5
4
7
Percent
51.9%
33.0%
31.4%
24.9%
19.5%
16.2%
15.1%
14.6%
12.4%
12.4%
11.4%
11.4%
9.7%
9.2%
4.9%
2.7%
2.7%
2.2%
3.8%
Respondents were significantly less likely to cite depression and anxiety as a serious community health
concern in 2014 than in 2009.
“Other” comments:
- All of the above
- Keeping good doctors
- Administration (2)
- Lack of competent leadership
- Too much legalistic thinking
- Lack of doctor with most patients unable to use the hospital
9
Components of a Healthy Community (Question 3)
2014 N= 185
2009 N= 218
Respondents were asked to identify the three most important things for a healthy community.
Fifty-six percent of respondents (n=104) indicated that “Access to healthcare and other services”
is important for a healthy community. “Good jobs and a healthy economy” was the second most
indicated component at 47.6% (n=88) and third was “Healthy behaviors and lifestyles” at 29.7%
(n=55). Respondents were asked to identify their top three choices, thus the percentages do not
add up to 100%.
Important Component
Access to healthcare and other services
Good jobs and a healthy economy
Healthy behaviors and lifestyles
Strong family life
High quality healthcare services
Religious or spiritual values
Good schools1
Emergency services
Low crime/safe neighborhoods2
Affordable housing3
Clean environment4
Community involvement5
Parks and recreation/fitness
Immunized children
Low level of domestic violence
Tolerance for diversity
Low death and disease rates
Arts and cultural events
Other
2009
Count
Percent
127
58.3%
88
40.4%
77
35.3%
72
33.0%
Not asked in 2009
44
20.2%
58
26.6%
Not asked in 2009
48
22.0%
45
20.6%
37
17.0%
29
13.3%
11
5.0%
Not asked in 2009
11
5.0%
13
6.0%
9
4.1%
3
1.4%
4
1.8%
1
Count
104
88
55
53
41
38
32
28
26
21
18
12
11
10
5
4
3
0
3
2014
Percent
56.2%
47.6%
29.7%
28.6%
22.2%
20.5%
17.3%
15.1%
14.1%
11.4%
9.7%
6.5%
5.9%
5.4%
2.7%
2.2%
1.6%
0
1.6%
Respondents indicated that good schools were an important component of a healthy community
significantly less often in 2014 than in 2009.
2
Low crime and safe neighborhoods was indicated by respondents significantly less often in 2014 than
in 2009.
3
Respondents indicated that affordable housing was an important component of a healthy community
significantly less often in 2014 than in 2009.
4
Significantly fewer respondents indicated that a clean environment was an important component of a
healthy community in 2014 than in 2009.
5
Community involvement was indicated by respondents significantly less often in 2014 than in 2009.
“Other” comments:
- We need more happy lifestyles with each other
- Equality in the healthcare system
10
Survey Findings – Awareness of Services
Overall Awareness of Health Services (Question 4)
2014 N= 181
2009 N= 205
Respondents were asked to rate their knowledge of the health services available at Marias
Medical Center. Forty-six percent (n=84) of respondents rated their knowledge of health services
as “Good.” Twenty-eight percent (n=50) rated their knowledge as “Fair” and 18.8% of
respondents (n=34) rated their knowledge as “Excellent.” Four respondents chose not to answer
this question.
11
How Respondents Learn of Healthcare Services (Question 5)
2014 N= 185
2009 N= 218
The most frequent method of learning about available services was “Word of mouth/reputation”
at 70.8% (n=131). “Friends/family” was the second most frequent response at 60.5% (n=112)
and “Healthcare provider” was reported at 43.2% (n=80). Respondents could select more than
one method so percentages do not equal 100%.
2009
Method
Word of mouth/reputation1
Friends/family
Healthcare provider
Newspaper
Radio2
Public health
Website/internet3
Presentations
Senior center
Other
1
Count
Percent
133
61.0%
Not asked in 2009
93
42.7%
84
38.5%
47
21.6%
Not asked in 2009
4
1.8%
10
4.6%
Not asked in 2009
15
6.9%
2014
Count
131
112
80
78
61
18
16
9
7
5
Percent
70.8%
60.5%
43.2%
42.2%
33.0%
9.7%
8.6%
4.9%
3.8%
2.7%
Respondents in 2014 were more likely to learn of healthcare services through word of
mouth/reputation than in 2009.
2
In 2014, significantly more respondents reported learning about community healthcare services via
radio than in 2009.
3
Respondents were significantly more likely to use the internet to learn of healthcare services in 2014
than in 2009.
“Other” comments:
- Postal services
- By using the services
12
Cross Tabulation of Service Knowledge and Learning about Services
Analysis was done to assess respondents’ knowledge of services available at Marias Medical
Center with how they learn about services available in their community. The chart below shows
the results of the cross tabulation. How respondents learned of healthcare services was a multiple
response item, thus totals do not add up to 100%.
KNOWLEDGE RATING OF MARIAS MEDICAL CENTER SERVICES
BY
HOW RESPONDENTS LEARN ABOUT HEALTHCARE SERVICES
Word of mouth/reputation
Friends/family
Healthcare provider
Newspaper
Radio
Public Health
Website/internet
Presentations
Excellent
20
(15.4%)
19
(17.1%)
16
(20.5%)
11
(14.5%)
8
(13.3%)
5
(29.4%)
6
(37.5%)
2
(25%)
Senior center
Other
13
3
(60%)
Good
60
(46.2%)
56
(50.5%)
46
(59%)
37
(48.7%)
30
(50%)
8
(47.1%)
5
(31.3%)
6
(75%)
4
(57.1%)
2
(40%)
Fair
41
(31.5%)
32
(28.8%)
15
(19.2%)
23
(30.3%)
16
(26.7%)
3
(17.6%)
4
(25%)
Poor
9
(6.9%)
4
(3.6%)
1
(1.3%)
5
(6.6%)
6
(10%)
1
(5.9%)
1
(6.3%)
Total
130
111
78
76
60
17
16
8
2
(28.6%)
1
(14.3%)
7
5
Other Community Health Resources Utilized (Question 6)
2014 N= 185
2009 N= 218
Respondents were asked which community health resources, other than the hospital or clinic,
they had used in the last three years. “Pharmacy” was the most frequently utilized community
health resource cited by respondents at 75.1% (n=139). “Eye doctor” was also a highly utilized
resource at 70.8% (n=131) followed by “Dentist” at 61.6% (n=114). Respondents could select
more than one resource so percentages do not equal 100%.
Resource
Pharmacy
Eye doctor1
Dentist
Chiropractor
Civic center
Public health department2
Massage therapy
Senior center
Alternative Medicine3
Transportation services
WIC
Mental health
Chemical dependency services
Other
1
2009
Count
Percent
175
80.3%
102
46.8%
124
56.9%
54
24.8%
Not asked in 2009
21
9.6%
33
15.1%
28
12.8%
6
2.8%
Not asked in 2009
Not asked in 2009
7
3.2%
Not asked in 2009
1
0.5%
Count
139
131
114
53
45
41
40
21
20
8
4
4
0
5
2014
Percent
75.1%
70.8%
61.6%
28.6%
24.3%
22.2%
21.6%
11.4%
10.8%
4.3%
2.2%
2.2%
0
2.7%
Significantly more respondents saw an eye doctor in the past three years in 2014 than in 2009.
The public health department was used significantly more often by respondents in 2014 than in 2009.
3
In 2014, respondents used alternative medicine significantly more often than in 2009.
2
“Other” comments:
- Dr. Clary’s office (2)
- Walking trail
14
Improvement for Community’s Access to Healthcare (Question 7)
2014 N= 185
2009 N= 218
Respondents were asked to indicate what they felt would improve their community’s access to
healthcare. Fifty-eight percent of respondents (n=107) reported that “More primary care
providers” would make the greatest improvement. Forty-two percent of respondents (n=77)
indicated “Improved quality of care” and 30.8% (n=57) indicated “More specialists” would
improve access to care. Respondents could select more than one method so percentages do not
equal 100%.
Improvement
More primary care providers1
Improved quality of care2
More specialists (OB/GYN, pediatrician, etc.)
Expanded outpatient hours
Health education services3
Health fair
Transportation assistance
Telemedicine
Cultural sensitivity
Other4
2009
Count
Percent
72
33.0%
41
18.8%
64
29.4%
52
23.9%
22
10.1%
19
8.7%
20
9.2%
7
3.2%
Not asked in 2009
10
4.6%
2014
Count
Percent
107
57.8%
77
41.6%
57
30.8%
35
18.9%
33
17.8%
20
10.8%
19
10.3%
13
7.0%
1
0.5%
29
15.7%
1
In 2014, respondents indicated that more primary care providers would improve access to healthcare
significantly more often than in 2009.
2
Respondents indicated that improved quality of care would improve access to healthcare significantly
more often in 2014 than in 2009.
3
Health education services was indicated as a method to improve access to healthcare by more
respondents in 2014 than in 2009.
4
In 2014, respondents were more likely to indicate ‘other’ improvements not listed as options.
“Other” comments:
- Affordable (5)
- Better administration (2)
- Quality doctors
- A new hospital
- Less drama with doctor, nurses, and
staff (3)
- Extended days of service outside of
Shelby
- Not to lose so many doctors
- Honesty within the system
- Alternative Medicine
- Doctors that know their jobs
15
-
Better hospital decisions
Better primary care providers
Home Health Care
Getting to know the doctors will
increase trust in doctors
Access to doctors of your choice
Totally new management. Trust is
gone; local costs exorbitant
Removal of Dr. Clary (4)
Change CEO and CFO
Allow Dr. Clary access to the ER (2)
Interest in Educational Classes/Programs (Question 8)
2014 N= 185
2009 N= 218
Respondents were asked if they would be interested in any educational classes/programs if
offered locally. The most highly indicated class/program indicated was “Weight loss” at 30.3%
of respondents (n=56). “Health and wellness” was selected by 28.1% of respondents (n=52) and
“Women’s health” followed at 22.7% (n=42). Respondents could select more than one method
so percentages do not equal 100%.
Class/Program
Weight loss1
Health and wellness2
Women’s health
Nutrition
First aid/CPR
Chronic pain management
Diabetes3
Living will/advanced directive
Alzheimer’s
Cancer4
Heart disease
Grief counseling
Support groups
Parenting
Men’s health
Child wellness
Mental health
Suicide awareness/prevention
Alcohol/substance abuse
Smoking cessation
Prenatal/birthing
Other
2009
Count
Percent
42
19.3%
38
17.4%
Not asked in 2009
Not asked in 2009
Not asked in 2009
Not asked in 2009
17
7.8%
Not asked in 2009
Not asked in 2009
13
6.0%
Not asked in 2009
Not asked in 2009
Not asked in 2009
8
3.7%
Not asked in 2009
Not asked in 2009
11
5.0%
Not asked in 2009
Not asked in 2009
Not asked in 2009
Not asked in 2009
6
2.8%
1
Count
56
52
42
41
34
33
28
26
24
24
18
16
15
14
14
12
12
11
10
9
8
8
2014
Percent
30.3%
28.1%
22.7%
22.2%
18.4%
17.8%
15.1%
14.1%
13.0%
13.0%
9.7%
8.6%
8.1%
7.6%
7.6%
6.5%
6.5%
5.9%
5.4%
4.9%
4.3%
4.3%
Respondents were more likely to express interest in a weight loss program in 2014 than in 2009.
Respondents indicated an interest in health and wellness programs more often in 2014 than in 2009.
3
Respondents were more likely to express interest in diabetes programs in 2014 than in 2009.
4
In 2014, respondents were more likely to express interest in classes regarding cancer than in 2009.
2
“Other” comments:
- Dr. Clary’s office
- Financial/estate planning
- Alternative Medicine
- How to treat people fairly and with respect
16
Economic Importance of Local Healthcare Providers and Services (Question 9)
2014 N= 181
2009 N= 212
The majority of respondents (84%, n=152) indicated that local healthcare providers and services
(i.e.: hospitals, clinics, nursing homes, assisted living, etc.) are “Very important” to the economic
well-being of the area. Sixteen percent of respondents (n=29) indicated they are “Important.” No
respondents indicated “Not important” or “Don’t know” and four respondents did not choose to
answer this question.
1
In 2014, respondents rated the economic importance of local healthcare providers significantly higher
than in 2009.
17
Survey Findings – Use of Healthcare Services
Utilization of Preventative Services (Question 10)
2014 N= 185
2009 N= 218
Respondents were asked if they had utilized any of the preventative services listed in the past
year. “Flu shot” was selected by 53% of respondents (n=98). Forty-eight percent of respondents
(n=88) indicated they received a “Routine health checkup/birthday lab” and 46.5% of
respondents (n=86) had a “Routine blood pressure check.” Respondents could select all that
apply, thus the percentages do not equal 100%.
Service
Flu shot
Routine health checkup/birthday lab1
Routine blood pressure check
Cholesterol check
Mammography
Pap smear
Immunizations
Prostate (PSA)
Colonoscopy
Children’s checkup/Well baby
None
Other
1
2009
Count
Percent
Not asked in 2009
70
32.1%
120
55.0%
111
50.9%
85
39.0%
Not asked in 2009
Not asked in 2009
48
22.0%
42
19.3%
Not asked in 2009
23
10.6%
7
3.2%
Count
98
88
86
83
65
53
47
33
27
25
17
8
2014
Percent
53.0%
47.6%
46.5%
44.9%
35.1%
28.6%
25.4%
17.8%
14.6%
13.5%
9.2%
4.3%
In 2014, significantly more respondents reported having a routine health checkup in the past year than
in 2009.
“Other” comments:
- Diabetic test
- Lab for INR’s [International Normalized Ratio blood test]
- Sports Physical (2)
18
Needed/Delayed Hospital Care During the Past Three Years (Question 11)
2014 N= 170
2009 N= 204
Thirty-seven percent of respondents (n=62) reported that they or a member of their household
thought they needed healthcare services but did not get it or had to delay getting it. Sixty-four
percent of respondents (n=108) felt they were able to get the healthcare services they needed
without delay and fifteen respondents chose not to answer this question.
1
Respondents were more likely to delay care in 2014 than in 2009.
19
Reasons for NOT Being Able to Receive Services or Delay in Receiving Healthcare Services
(Question 12)
2014 N= 62
2009 N= 54
For those who indicated they were unable to receive or had to delay services (n=62), the reasons
most cited were: “It costs too much” (38.7%, n=24), “Don’t like doctors” (25.8%, n=16), and
“Too long to wait for an appointment” (21%, n=13). Respondents were asked to indicate their
top three choices, thus percentages do not total 100%.
Reason
It costs too much
Don’t like doctors
Too long to wait for an appointment
Could not get an appointment1
Privacy concerns
No insurance2
Office wasn’t open when I could go
My insurance didn’t cover it
Not treated with respect
Could not get off work
Too nervous or afraid
Unsure if services were available
Didn’t know where to go
Had no one to care for the children
It was too far to go
Transportation problems
Language barrier
Other
2009
Count
Percent
29
53.7%
13
24.1%
10
18.5%
3
5.6%
Not asked in 2009
17
31.5%
4
7.4%
5
9.3%
11
20.4%
5
9.3%
3
5.6%
2
3.7%
2
3.7%
2
3.7%
1
1.9%
1
1.9%
0
0
7
13.0%
Count
24
16
13
12
9
8
8
7
6
5
4
4
3
2
1
1
0
16
2014
Percent
38.7%
25.8%
21.0%
19.4%
14.5%
12.9%
12.9%
11.3%
9.7%
8.1%
6.5%
6.5%
4.8%
3.2%
1.6%
1.6%
0
25.8%
1
In 2014, significantly more respondents indicated they did not receive medical services because they
could not get an appointment than in 2009.
2
Significantly fewer respondents in 2014 reported they delayed receiving care because they had no
insurance than in 2009.
“Other” comments:
- Did not feel I needed care
- Needed specialist
- Doctors change too often (2)
- No local provider
- Doctor canceled appointment
- Don’t like specific doctor on call (2)
- Couldn’t see my own doctor
- Management of clinic and hospital
- The hospital board should work for
the people not their own likes or
20
-
dislikes. The hospital board got rid
of a very well-liked doctor. The
board should not be so judgmental,
and treat people fairly.
Family doctor not allowed on
premises (2)
Main caregiver/doctor was fired (3)
Do not want to support hospital
under current administration
Desired Local Healthcare Services (Question 13)
2014 N= 185
2009 N= 218
Respondents were asked to indicate which healthcare professionals or services presently not
available would they use if available locally. Respondents indicated the most interest in having
“Dermatology” services available at 26.5% (n=49) followed by “Senior well checks” at 22.2%
(n=41), then “Podiatry (foot care)” at 18.4% (n=34). Respondents were asked to select all that
apply so percentages do not equal 100%.
Service
Dermatology1
Senior well checks
Podiatry (foot care)
Chronic pain specialist
Pulmonary/cardiac rehab
Home health/hospice
Orthopedics
Oncology
Family planning
Other
1
2009
Count
Percent
39
17.9%
Not asked in 2009
Not asked in 2009
Not asked in 2009
Not asked in 2009
Not asked in 2009
22
10.1%
Not asked in 2009
Not asked in 2009
20
9.2%
Count
49
41
34
31
19
17
17
9
7
13
2014
Percent
26.5%
22.2%
18.4%
16.8%
10.3%
9.2%
9.2%
4.9%
3.8%
7.0%
Significantly more respondents would like dermatology services available locally in 2014 than in 2009.
“Other” comments:
- Dermatologist
- Endocrinology
- Alternative Medicine
- Allergist
- Reflexology
- Mental health
21
Hospital Care Received in the Past Three Years (Question 14)
2014 N= 178
2009 N= 206
Seventy-three percent of respondents (n=129) reported that they or a member of their family had
received hospital care (i.e. hospitalized overnight, day surgery, obstetrical care, rehabilitation,
radiology, or emergency care) during the previous three years. Twenty-eight percent (n=49) had
not received hospital services and seven respondents chose not to answer this question.
22
Hospital Used Most in the Past Three Years (Question 15)
2014 N= 113
2009 N= 147
Of the 129 respondents who indicated receiving hospital care in the previous three years, 59.3%
(n=67) reported receiving care at Marias Medical Center in Shelby. Twenty-one percent of
respondents (n=24) went to Benefis in Great Falls and 9.7% of respondents (n=11) utilized
services at Kalispell Region Medical Center in Kalispell. Sixteen of the 129 respondents who
reported they had been to a hospital in the past three years did not indicate which hospital they
had utilized.
Hospital
Marias Medical Center (Shelby)
Benefis (Great Falls)
Kalispell Regional Medical Center (Kalispell)
Pondera Medical Center (Conrad)
Northern Rockies Medical Center (Cut Bank)
Liberty Medical Center (Chester)
VA (Helena)
Other
TOTAL
2009
Count Percent
92
62.6%
27
18.4%
8
5.4%
11
7.5%
6
4.0%
1
0.7%
0
0
2
1.4%
147
100%
“Other” comments:
- Depends on services needed
- Flathead Orthopedics
- Billings
- Out of state
- St. Patrick Hospital in Missoula, MT
- Lack of doctor with most patients unable to use the hospital
23
2014
Count Percent
67
59.3%
24
21.2%
11
9.7%
3
2.7%
2
1.8%
1
0.9%
0
0
5
4.4%
113
100%
Reasons for Selecting the Hospital Used (Question 16)
2014 N= 129
2009 N= 160
Of the 129 respondents who had a personal or family experience at a hospital within the past
three years, the primary reason given for selecting the facility used most often was “Closest to
home” at 60.5% (n=78). “Prior experience with hospital” was selected by 45.7% of the
respondents (n=59) and 41.9% (n=54) selected “Referred by physician.” Note that respondents
were asked to select the top three answers which influenced their choices; therefore the
percentages do not equal 100%.
Reason
Closest to home
Prior experience with hospital
Referred by physician
Hospital’s reputation for quality
Emergency, no choice
Recommended by family or friends
Closest to work
Cost of care
VA/Military requirement
Required by insurance plan
Other
2009
Count
Percent
102
63.8%
86
53.8%
56
35.0%
49
30.6%
45
28.1%
16
10.0%
23
14.4%
17
10.6%
5
3.1%
1
0.6%
15
9.4%
“Other” comments:
- Where services are available
- Doctor we chose
- Competent doctors
- Attention to service
- Services not available closer to home
- Specialist availability/care procedures not available locally
- Not comfortable with quality of local doctors
24
2014
Count
78
59
54
42
36
13
12
9
4
2
13
Percent
60.5%
45.7%
41.9%
32.6%
27.9%
10.1%
9.3%
7.0%
3.1%
1.6%
10.1%
Cross Tabulation of Hospital and Residence
Analysis was done to examine where respondents utilized hospital services the most in the past
three years with where they live by zip code. The chart below shows the results of the cross
tabulation. Hospital location is across the top of the table and residents’ zip codes are along the
side.
LOCATION OF MOST OFTEN UTILIZED HOSPITAL BY RESIDENCE
Marias
Medical
Center
(Shelby)
Shelby
59474
Sunburst
59482
Valier
59486
Cut Bank
59427
Conrad
59425
Chester
59522
Oilmont
59466
Kevin
59454
Galata
59444
Sweet Grass
59484
53
(64.6%)
9
(75%)
3
(30%)
25
14
(17.1%)
2
(16.7%)
5
(50%)
2
(50%)
Pondera
Medical
Center
(Conrad)
Northern
Rockies
Medical
Center
(Cut Bank)
Liberty
Medical
Center
(Chester)
1
(1.2%)
Other
Total
5
(6.1%)
82
12
1
(10%)
10
2
(50%)
4
1
(100%)
1
1
(100%)
1
1
(100%)
1
(100%)
1
1
0
0
67
(59.8%)
TOTAL
Benefis
(Great
Falls)
Kalispell
Regional
Medical
Center
(Kalispell)
9
(11%)
1
(8.3%)
1
(10%)
23
(20.5%)
11
(9.8%)
3
(2.7%)
2
(1.8%)
1
(0.9%)
5
(4.5%)
112
(100%)
Cross Tabulation of Hospital and Reason Selected
Analysis was done to assess respondents’ most utilized hospital with why they selected that
hospital. The chart below shows the results of the cross tabulation. Reason hospital was selected
was a multiple response item, thus totals do not add up to 100%. Hospital location is across the
top of the table and reason for selection is along the side.
LOCATION OF MOST UTILIZED HOSPITAL BY REASONS HOSPITAL SELECTED
Marias
Medical
Center
(Shelby)
61
(84.7%)
9
(81.8%)
22
(73.3%)
4
(80%)
4
(5.6%)
1
(9.1%)
6
(20%)
10
(27.8%)
13
(36.1%)
32
(62.7%)
1
(10%)
20
(41.7%)
1
(50%)
2
(100%)
6
(54.5%)
9
(17.6%)
2
(20%)
17
(35.4%)
1
(50%)
Cost of care
Closest to home
Closest to work
Emergency, no
choice
Hospital’s
reputation for
quality
Prior experience
with hospital
Recommended by
family or friends
Referred by
physician
Required by
insurance plan
VA/Military
requirement
Other
26
Benefis
(Great
Falls)
Kalispell
Regional
Medical
Center
(Kalispell)
1
(20%)
2
(2.8%)
Pondera
Medical
Center
(Conrad)
Northern
Rockies
Medical
Center
(Cut Bank)
Liberty
Medical
Center
(Chester)
Other
Total
5
1
(1.4%)
2
(2.8%)
1
(1.4%)
1
(9.1%)
1
(1.4%)
72
11
1
(3.3%)
1
(3.3%)
9
(25%)
1
(2.8%)
1
(2.8%)
2
(5.6%)
4
(7.8%)
4
(40%)
5
(10.4%)
3
(5.9%)
2
(20%)
1
(2.1%)
1
(2%)
2
(3.9%)
1
(10%)
5
(10.4%)
30
36
51
10
48
2
2
4
(36.4%)
1
(9.1%)
11
Overall Quality of Care at Marias Medical Center (Question 17)
2014 N= 185
2009 N= 218
Respondents were asked to rate a variety of aspects of the overall care provided at Marias
Medical Center using the scale of 4=Excellent, 3=Good, 2=Fair, 1=Poor, and “Don’t know.” The
sums of the average scores were then calculated with “Ambulance service” receiving the top
average score of 3.7 out of 4.0. “Radiology” received a score of 3.5 and “Dentistry” received a
3.4 out of 4.0. The total average score was 3.2, indicating the overall services of the hospital to
be “Excellent” to “Good.”
2014
Ambulance service1
Radiology
Dentistry
Laboratory
Physical therapy
Speech therapy
Assisted living
Occupational therapy2
Visiting specialists
Emergency room
Ophthalmology services
General surgery
Obstetrics
Extended care (nursing
home)
Hospice
Sleep studies3
TOTAL
Excellent Good
(4)
(3)
64
26
57
40
39
30
62
63
37
30
10
7
21
21
25
23
30
37
37
67
10
7
17
26
7
15
Fair
(2)
2
3
5
12
7
0
7
2
2
11
1
10
3
Poor Don’t
(1) know
0
82
2
68
2
95
4
32
4
93
2
148
3
119
5
118
5
99
9
48
3
144
4
112
2
136
No
Ans.
11
15
14
12
14
18
14
12
12
13
20
16
22
N
Avg
185
185
185
185
185
185
185
185
185
185
185
185
185
3.7
3.5
3.4
3.3
3.3
3.3
3.2
3.2
3.2
3.1
3.1
3.0
3.0
11
30
11
6
113
14
185
2.8
5
8
440
14
11
447
1
1
80
4
9
62
143
131
18
25
185
185
2.8
2.6
3.2
1
Ambulance service received a significantly higher rating in 2014 than in 2009.
Occupational therapy received a significantly higher rating in 2014 than in 2009.
3
Sleep studies received a significantly lower rating in 2014 than in 2009.
2
Question 17 continued on the following page…
27
Question 17 continued…
2009
Excellent
(4)
57
25
76
18
60
27
10
31
59
10
26
15
5
8
Good
(3)
18
16
68
14
51
34
10
29
65
9
37
22
8
13
Fair
(2)
2
4
13
3
8
7
2
5
19
3
8
7
0
7
Poor Don’t
(1) know
4
127
2
158
2
46
1
166
1
82
1
135
1
181
3
136
4
59
1
181
1
134
2
157
2
188
1
174
Ambulance service1
Dentistry
Laboratory
Obstetrics
Radiology
General surgery
Ophthalmology services
Physical therapy
Emergency room
Hospice
Visiting specialists
Assisted living
Sleep studies3
Occupational therapy2
Extended care (nursing
8
16
17
7
158
home)
TOTAL
435
410
105
33
*Please see corresponding significance statements on previous page…
28
No
Ans.
10
13
13
16
16
14
14
14
12
14
12
15
15
15
N
Avg
218
218
218
218
218
218
218
218
218
218
218
218
218
218
3.6
3.4
3.4
3.4
3.4
3.3
3.3
3.3
3.2
3.2
3.2
3.1
3.1
3.0
12
218
2.5
3.3
Primary Care Received in the Past Three Years (Question 18)
2014 N= 178
2009 N= 213
Ninety-eight percent of respondents (n=174) indicated that they or someone in their household
had been seen by a primary care provider (such as a family physician, physician assistant, or
nurse practitioner) for healthcare services in the past three years. Two percent of respondents
(n=4) had not seen a primary care provider and six respondents chose not to answer this
question.
29
Location of Primary Care Provider (Question 19)
2014 N= 153
Of the 174 respondents who indicated receiving primary care services in the previous three
years, 69.3% (n=106) reported receiving care in Shelby at Marias Healthcare Services, Inc. Five
percent of respondents (n=8) went to Benefis in Great Falls and 13.7% of respondents (n=21)
utilized primary care services at a location not listed. Twenty-one of the 174 respondents who
reported they had utilized primary care services in the past three years did not indicate where
they received those services.
Clinic Location
Marias Healthcare Services, Inc. (Shelby)
Benefis (Great Falls)
Northern Rockies Medical Center (Cut Bank)
Great Falls Clinic (Great Falls)
Kalispell Regional Medical Center (Kalispell)
Pondera Medical Center (Conrad)
VA Clinic (Helena)
Liberty Medical Center (Chester)
Other
TOTAL
2014*
Count
Percent
106
69.3%
8
5.2%
5
3.3%
4
2.6%
4
2.6%
2
1.3%
2
1.3%
1
0.7%
21
13.7%
153
100%
*Responses from 2009 are not comparable to 2014 data because respondents could choose multiple
locations for primary care in 2009.
“Other” comments:
- Dr. Clary (15)
- Private clinic in Great Falls, MT
- Sunburst, MT (2)
- Glacier Community Health Center (3)
- Private practice
- Marias Healthcare Services until they fired my doctor after he had given over 30 years of
his life [working at Marias Medical Center]
30
Reasons for Selection of Primary Care Provider (Question 20)
2014 N= 174
2009 N= 211
Those respondents who indicated they or someone in their household had been seen by a primary
care provider within the past three years were asked to indicate why they chose that primary care
provider. “Prior experience with clinic” (49.4%, n=86) was the most frequently cited factor
followed by “Closest to home” (47.7%, n=83) and “Appointment availability” at 23% (n=40).
Respondents were asked to select all that apply so the percentages do not equal 100%.
Reason
Prior experience with clinic
Closest to home1
Appointment availability
Clinic’s reputation for quality
Recommended by family or friends
Referred by physician or other provider
Length of waiting room time
VA/Military requirement
Required by insurance plan
Cost of care2
Indian Health Services
Other
Count
94
122
56
43
32
21
20
11
1
14
2
27
2009
Percent
44.5%
57.8%
26.5%
20.4%
15.2%
10.0%
9.5%
5.2%
0.5%
6.6%
0.9%
12.8%
Count
86
83
40
37
28
20
13
5
4
3
0
27
2014
Percent
49.4%
47.7%
23.0%
21.3%
16.1%
11.5%
7.5%
2.9%
2.3%
1.7%
0
15.5%
1
In 2014, respondents were significantly less likely to choose a primary care provider because they were
located close to home.
2
Cost of care was cited significantly less often by respondents in 2014 than in 2009.
“Other” comments:
- Dr. Clary’s knowledge and experience (7)
- Because he [primary care provider] had treated me since he came here [Marias Medical
Center]. He knows me inside and out. I trust him with my life.
- Nice people who actually acted like they cared
- Family Doctor (5)
- Costs in Shelby are too high
- Privacy concerns
- Only available specialist
- Experience with physician
- Doctor’s reputation (3)
- Our family physician (2)
- Woman
- Not Robert Clary
31
Cross Tabulation of Primary Care and Residence
Analysis was done to examine where respondents went most often for primary care with where
they live by zip code. The chart below shows the results of the cross tabulation. Clinic location is
across the top of the table and residents’ zip codes are along the side.
TOTAL
1
(0.9%)
6
(5.1%)
1
(7.1%)
1
(11.1%)
1
(0.9%)
1
(7.1%)
2
(22.2%)
1
(0.9%)
19
(16.2%)
117
14
9
3
(75%)
1
(25%)
2
(100%)
1
(50%)
Total
Other
VA Clinic
(Helena)
1
(0.9%)
Kalispell
Regional
Medical Center
(Kalispell)
4
(3.4%)
Liberty
Medical Center
(Chester)
Pondera
Medical Center
(Conrad)
84
(71.8%)
12
(85.7%)
6
(66.7%)
Great Falls
Clinic
(Great Falls)
Shelby
59474
Sunburst
59482
Valier
59486
Cut Bank
59427
Oilmont
59466
Kevin
59454
Conrad
59425
Chester
59522
Galata
59444
Sweet Grass
59484
Benefis
(Great Falls)
Marias
Healthcare
Services, Inc.
(Shelby)
Northern
Rockies
Medical Center
(Cut Bank)
LOCATION OF PRIMARY CARE PROVIDER MOST UTILIZED BY RESIDENCE
4
2
1
(50%)
2
1
(100%)
1
1
(100%)
1
1
(100%)
1
0
106
(70.2%)
32
4
(2.6%)
8
(5.3%)
4
(2.6%)
2
(1.3%)
1
(0.7%)
4
(2.6%)
2
(1.3%)
20
(13.2%)
151
Cross Tabulation of Clinic and Reason Selected
Analysis was done to examine where respondents went most often for primary care services with
why they selected that clinic/provider. The chart below shows the results of the cross tabulation.
Reason clinic/provider was selected was a multiple response item, thus totals do not add up to
100%.
Appointment
availability
Clinic’s
reputation for
quality
Closest to home
27
(77.1%)
2
(5.7%)
1
(2.9%)
13
(44.8%)
1
(3.4%)
3
(10.3%)
68
(94.4%)
2
(2.8%)
Cost of care
Length of
waiting room
time
Prior
experience with
clinic
Recommended
by family or
friends
Referred by
physician or
other provider
Required by
insurance plan
VA/Military
requirement
Indian Health
Services
3
(33.3%)
3
(10.3%)
1
(1.4%)
Total
Other
VA Clinic
(Helena)
Kalispell
Regional
Medical Center
(Kalispell)
Liberty Medical
Center
(Chester)
2
(6.9%)
1
(2.9%)
4
(11.4%)
35
1
(3.4%)
6
(20.7%)
29
1
(1.4%)
72
1
(50%)
1
(50%)
1
(11.1%)
2
(22.2%)
1
(11.1%)
2
(22.2%)
9
3
(4.2%)
1
(1.4%)
9
(12.5%)
72
3
(12.5%)
4
(16.7%)
24
1
(6.3%)
1
(6.3%)
16
46
(63.9%)
3
(4.2%)
4
(5.6%)
3
(4.2%)
12
(50%)
2
(8.3%)
2
(8.3%)
1
(4.2%)
13
(81.3%)
Pondera Medical
Center
(Conrad)
Great Falls
Clinic
(Great Falls)
Benefis
(Great Falls)
Northern
Rockies Medical
Center
(Cut Bank)
Marias
Healthcare
Services, Inc.
(Shelby)
LOCATION OF PRIMARY CARE PROVIDER BY REASONS CLINIC SELECTED
1
(6.3%)
2
(2.8%)
1
(1.4%)
2
3
(100%)
3
1
(50%)
1
(50%)
2
0
11
(42.3%)
Other
33
1
(3.8%)
2
(7.7%)
1
(3.8%)
11
(42.3%)
26
Use of Healthcare Specialists during the Past Three Years (Question 21)
2014 N= 170
2009 N= 206
Eighty-four percent of respondents (n=143) indicated they or a household member had seen a
healthcare specialist during the past three years. Sixteen percent (n=27) indicated they had not
seen a specialist and fifteen respondents chose not to answer this question.
34
Type of Healthcare Specialist Seen (Question 22)
2014 N= 143
2009 N= 173
The respondents saw a wide array of healthcare specialists in the past three years. The most
frequently indicated specialist was a “Dentist” at 45.5% of respondents (n=65) having utilized
their services. “Chiropractor” was the second most utilized specialist at 22.4% (n=32) and both
“Cardiologist” and “OB/GYN” were third at 20.3% (n=29). Respondents were asked to choose
all that apply so percentages do not equal 100%.
Healthcare Specialist
Dentist1
Chiropractor
Cardiologist
OB/GYN
Radiologist2
General surgeon
Orthopedic surgeon
Gastroenterologist
Dermatologist
Oncologist3
Ophthalmologist4
Urologist
ENT (ear/nose/throat)
Neurologist
Podiatrist
Pulmonologist
Endocrinologist
Neurosurgeon
Mental health counselor
Psychologist
Dietician
Rheumatologist
Allergist
Pediatrician
Psychiatrist (M.D.)
Substance abuse counselor
Other
2009
Count
Percent
111
64.2%
37
21.4%
39
22.5%
23
13.3%
100
57.8%
31
17.9%
38
22.0%
Not asked in 2009
17
9.8%
13
7.5%
89
51.4%
23
13.3%
16
9.2%
21
12.1%
9
5.2%
8
4.6%
Not asked in 2009
Not asked in 2009
6
3.5%
5
2.9%
3
1.7%
9
5.2%
Not asked in 2009
6
3.5%
2
1.2%
0
0
17
9.8%
1
2014
Count
65
32
29
29
26
24
24
24
23
21
19
18
14
9
9
8
8
8
6
5
4
4
4
3
3
3
13
2014 respondents were significantly less likely to have visited a dentist than in 2009.
Significantly fewer people saw a radiologist in 2014 than in 2009.
3
In 2014, respondents were significantly more likely to have seen an oncologist.
4
In 2014, significantly fewer people reported utilizing an ophthalmologist than in 2009.
2
Question 22 continued on following page…
35
Percent
45.5%
22.4%
20.3%
20.3%
18.2%
16.8%
16.8%
16.8%
16.1%
14.7%
13.3%
12.6%
9.8%
6.3%
6.3%
5.6%
5.6%
5.6%
4.2%
3.5%
2.8%
2.8%
2.8%
2.1%
2.1%
2.1%
9.1%
Question 22 continued…
“Other” comments:
- Seizure disorder specialist
- Hematologist
- Plastic surgeon (2)
- Rheumatologist
- Pain management
- Naturopath
- Cancer specialist (2)
- Kidney doctor
- Ultrasound
- Colonoscopy
- Eye doctor (2)
- Flight physician
- Bladder infection
- Anesthesiologist
- Orthopedic surgeon
36
Location of Healthcare Specialist (Question 23)
2014 N= 143
2009 N= 173
Of the 143 respondents who indicated they saw a healthcare specialist in the past three years,
67.8% (n=97) saw one in Great Falls. Shelby was utilized by 39.9% (n=57) of respondents for
specialty care and Kalispell was reported by 27.3% (n=39). Respondents could select more than
one location; therefore percentages do not equal 100%.
Location
Great Falls
Shelby
Kalispell
Cut Bank
Conrad
Helena
Missoula
Other
“Other” comments:
- Phoenix, AZ
- Billings (5)
- Browning
- Chicago, IL
- Chester
37
2009
Count
Percent
118
68.2%
67
38.7%
34
19.7%
24
13.9%
19
11.0%
6
3.5%
10
5.8%
20
11.6%
2014
Count
97
57
39
17
11
7
6
15
Percent
67.8%
39.9%
27.3%
11.9%
7.7%
4.9%
4.2%
10.5%
Survey Findings – Personal Health
Prevalence of Depression (Question 24)
2014 N= 185
Respondents were asked to indicate if there were periods of at least three consecutive months in
the past three years where they felt depressed on most days, although they may have felt okay
sometimes. Fourteen percent of respondents (n=25) indicated they had experienced periods of
feeling depressed and 80% of respondents (n=148) indicated they had not. Seven percent of
respondents (n=12) chose not to answer this question.
38
Physical Activity (Question 25)
2014 N= 185
Respondents were asked to indicate how frequently they had physical activity for at least twenty
minutes over the past month. Thirty-five percent of respondents (n=65) indicated they had
physical activity of at least twenty minutes “Daily” over the past month and 34.6% (n=64)
indicated they had physical activity “2-4 times per week.” Four percent of respondents (n=7)
indicated they had “No physical activity” and five respondents chose not to answer this question.
39
Survey Findings – Cost and Health Insurance
Medical Insurance (Question 26)
2014 N= 155
Respondents were asked to indicate what type of medical insurance covers the majority of their
medical expenses. Fifty-four percent (n=83) indicated they have “Employer sponsored”
coverage. Twenty-four percent (n=37) indicated they have “Medicare” then “Private
insurance/private plan” was indicated by 11% of respondents (n=17). Thirty respondents chose
not to answer this question.
2014*
Insurance Type
Employer sponsored
Medicare
Private insurance/private plan
Medicaid/Healthy MT Kids Plus
VA/Military
State/other
None/Pay out of pocket
Health Insurance Marketplace
Health Savings Account
Indian Health
Other
TOTAL
Count
83
37
17
4
4
2
2
1
1
1
3
155
Percent
53.5%
23.9%
11.0%
2.6%
2.6%
1.3%
1.3%
0.6%
0.6%
0.6%
2.0%
100%
*In 2009, respondents could select more than one type of insurance so the results are not comparable to
2014 responses.
40
Insurance and Healthcare Costs (Question 27)
2014 N= 177
2009 N= 196
Respondents were asked to indicate how well they felt their health insurance covers their
healthcare costs. Fifty percent of respondents (n=89) indicated they felt their insurance covers a
“Good” amount of their healthcare costs. Twenty-seven percent of respondents (n=48) indicated
they felt their insurance is “Excellent” and 16.4% of respondents (n=29) indicated they felt their
insurance coverage was “Fair.”
41
Barriers to Having Health Insurance (Question 28)
2014 N= 2
2009 N= 20
Those respondents who indicated they did not have medical insurance (n=2) were asked to
indicate why they did not. Fifty percent (n=1) reported they did not have health insurance
because they could not afford to pay for it and 50% (n=1) indicated they did not have medical
insurance for “Other” reasons. Respondents were asked to mark all answers that applied, thus
the percentages may not equal 100%.
Reason
Cannot afford to pay for medical insurance
Employer does not offer insurance
Cannot get medical insurance due to
medical issues
Other
“Other” comments:
- IHS [Indian Health Services]
42
Count
17
4
2009
Percent
85.0%
20.0%
Count
1
0
4
20.0%
0
2
10.0%
1
2014
Percent
50.0%
0
0
50.0%
Awareness of Health Payment Programs (Question 29)
2014 N= 151
2009 N= 203
Respondents were asked to indicate their awareness of programs that help people pay for
healthcare bills. Sixty-one percent of respondents (n=92) indicated they were aware of these
types of programs, but did not qualify to utilize them. Twenty percent (n=30) indicated that they
were not aware or did not know of these programs and 8.6% of respondents (n=13) indicated
they were aware of and utilized health payment assistance programs. Thirty-four respondents
chose not to answer this question.
43
Cost and Prescription Medications (Question 30)
2014 N= 168
Respondents were asked to indicate if medication costs had prohibited them from getting a
prescription or taking their medication regularly. Eighteen percent of respondents (n=30)
indicated that, in the last year, cost had prohibited them from getting a prescription or taking
their medication regularly. Eighty-two percent of respondents (n=138) indicated that cost had not
prohibited them, and seventeen respondents chose not to answer this question.
44
VI. Focus Group Methodology
Three focus groups were held in Shelby, Montana in June 2014. Focus group participants were
identified as people living in Marias Medical Center’s service area.
Forty-one people participated in the three focus group interviews. The focus groups were
designed to represent various consumer groups of healthcare including senior citizens and local
community members. Focus groups were held at Marias Medical Center, Marias Electric, and
the senior center. Each group meeting lasted up to 90 minutes in length and followed the same
line of questioning in each session (Appendix F). The questions and discussions at the focus
groups were led by Kailyn Dorhauer with the Montana Office of Rural Health.
Focus group notes can be found in Appendix G of this report.
45
VII. Focus Group Findings
The following key findings, themes, and health needs emerged from the responses which
participants gave to the line of questioning found in Appendix F.
Improve health of the community:
 Wellness programs/classes
 Affordable and high-quality healthy food
 Community connectedness
 Educating community members regarding the importance of preventative care
Most important local healthcare issues:
 Lack of home healthcare
 Alcohol, tobacco, prescription/other drug abuse
 Lack of volunteerism
 Mental health services
 Nutrition
 High doctor turnover rates at Marias Medical Center
Opinion of hospital services:
 Quality of care at Marias Medical Center is great
 A recent transition in providers has affected the entire community
 Participants felt that Marias Medical Center provides a large number of services,
especially in comparison to other rural hospitals
 More specialists are needed at Marias Medical Center
 Participants felt that the hospital board is lacking leadership and does not effectively
communicate with community members
 Distinguishing whether healthcare bills are from the clinic or hospital can be
confusing to community members
 Signs and a main desk in the hospital would help direct patients to their destination
 Privacy issues were voiced regarding the waiting room
 The dentist is great, but it is difficult to make an appointment because he is so busy
Reasons for using local providers:
 Some participants prefer to use local providers to support their community, for
convenience, and to minimize travel
46
Opinion of local services:
 The Emergency Room staff are quick, efficient, and provide excellent care
 Ambulance services are great, but more volunteers would be beneficial
 The rural clinics are very helpful for those who live in Sunburst and Valier
 Marias Medical Center does a good job assisting those in the area who cannot afford
to pay for healthcare through Hill-Burton funds
 The Public Health Department is a valuable resource for the community, but
participants mentioned that more marketing regarding the services they offer would
be useful
 The Heritage Center provides outstanding care and is perceived very highly by
community members
 The Care Center also provides great care and community members are pleased with
the recent additions to the Alzheimer’s Disease wing
Reasons to leave the community for healthcare:
 Planned parenthood services, Obstetric (OB) services, and pediatric care because they
are not offered locally
 The recent transition in providers and leadership style of the Hospital Board have
caused some community members to seek care elsewhere
 Privacy concerns
 Participants mentioned that some community members choose to follow their
provider if the provider begins working elsewhere
Needed healthcare services in the community:
 Bringing back the Health Fair
 Pediatric care
 Obstetric (OB) services
47
VIII. Summary
One hundred eighty-five surveys were completed in Marias Medical Center’s service area for a
25% response rate. Of the 185 returned, 69.8% of the respondents were females, 61.9% were 56
years of age or older, and 48% work full time.
Respondents rated the overall quality of care at the hospital as excellent to good, scoring 3.2 out
of 4.0 on a scale of 4.0 being excellent and 1.0 being poor.
Over half of the respondents (54.9%) feel the Shelby area is a “somewhat healthy” place to live.
Significantly fewer respondents rated the Shelby area as very healthy or healthy in 2014 than in
2009.
Respondents indicated their top three health concerns were: alcohol abuse/substance abuse
(51.9%), obesity/poor nutrition (33%), and cancer (31.4%).
When respondents were asked which health related educational programs or classes they would
be most interested in, the top choices were: weight loss (30.3%), health and wellness (28.1%),
and women’s health (22.7%).
Overall, the respondents within Marias Medical Center’s service area are seeking hospital care at
a rate that is typically seen in rural areas. Area residents recognize the major impact the
healthcare sector has on the economic well-being of the area, with 84% of respondents
identifying local healthcare services as “very important” to the economic well-being of the area.
The majority of participants appeared to have very favorable opinions of the services with most
praising the care received. Participants were appreciative of the care available while identifying
additional services or needs.
In summary, respondents report support for local healthcare and many prefer to seek care locally
whenever possible for convenience and out of trust for local providers.
48
Appendix A – Steering Committee Members
Steering Committee – Name and Organization Affiliation
1. Anna Clark – Marias Medical Center
2. Brenda Gilmore – Social Services Director, Marias Medical Center
3. Jessica Brusven – Toole County Health Foundation Director & Better Health
Improvement Specialist, Marias Medical Center
4. Judy Richman– Director, Marias Heritage Center
5. Julia Drishinski – RN/Director of Education and Infection Control, Marias Medical
Center
6. Justin Perry – DPT/Director of Rehabilitation Services, Marias Medical Center
7. Kim Schilt – Director of Nursing, Marias Medical Center
8. Kristi Aklestad – RN, Toole County Health Department
9. Leorra Nickol – Youth Dynamics
10. Lorette Carter – Community Economic Development Director, City of Shelby
11. Marcia Heydon – Business Office Manager, Marias Medical Center
12. Peggy Taylor – Shelby Elementary School
13. Rikki James – MTUPP/CIAA Coordinator, Toole County Health Department
14. Tressa Keller – IT Tech, Marias Medical Center
15. Toni Moberly – RN/Montana Cancer Control Program, County Health Department
16. Vicky Warila – Youth Dynamics
49
Appendix B – Public Health and Populations Consultation
Public Health and Populations Consultation Worksheet
1. Public Health
a. Name/Organization
Kristi Aklestad – RN, Toole County Health Department
Rikki James – Montana Tobacco Use Prevention Program/Clean Indoor Air Act
Coordinator, Toole County Health Department
Toni Moberly – RN/Montana Cancer Control Program, Toole County Health
Department
b. Date of Consultation
First Steering Committee Meeting:
January 28, 2014
c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)
Steering Committee
d. Input and Recommendations from Consultation
- Look at Benefis community health needs assessment survey data
- Many people don’t know what services the health department offers
- Have other questions they would like to include in the survey (referred to as
Appendix B)
2. Populations Consultation (a leader or representative of populations such as medically
underserved, low-income, minority and/or populations with chronic disease)
Population: Low-Income, Underinsured
a. Name/Organization
Kristi Aklestad – RN, Tool County Health Department
b. Date of Consultation
First Steering Committee Meeting:
January 28, 2014
c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)
Steering Committee
d. Input and Recommendations from Consultation
- Noted that Healthy Montana Kids Plus is different than Health Montana Kids
- People use both options in this area
- Healthy Montana Kids is like Medicaid for kids
50
Population: Seniors
a. Name/Organization
Brenda Gilmore – Social Services, Marias Medical Center
b. Date of Consultation
First Steering Committee Meeting:
January 28, 2014
c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)
Steering Committee
d. Input and Recommendations from Consultation
- There is a need for senior wellness checks
Population: Youth
a. Name/Organization
Peggy Taylor – Principal, Shelby Elementary School
Vicky Warila – Youth Dynamics
Leorra Nickol – Youth Dynamics
b. Date of Consultation
First Steering Committee Meeting:
January 28, 2014
c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)
Steering Committee
d. Input and Recommendations from Consultation
- Schools have been trying to provide more suicide prevention information
- Prenatal, birthing, and breastfeeding classes would be beneficial to have in Shelby
Population: Tribal/American Indian
a. Name/Organization
No Specific Representatives
b. Date of Consultation
First Steering Committee Meeting:
January 28, 2014
c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)
Steering Committee
d. Input and Recommendations from Consultation
- Marias Medical Center can accept Indian Health Service (IHS) patients if they are
referred
51
Appendix C – Survey Cover Letter
52
Appendix D – Survey Instrument
53
54
55
56
57
58
Appendix E – Responses to Other and Comments
2. In the following list, what do you think are the three most serious health concerns in our
community?
 All of the above
 Keeping good doctors
 Administration (2)
 Lack of competent leadership
 Too much legalistic thinking
 Lack of doctor with most patients unable to use the hospital
3. Select the three items below that you believe are most important for a healthy community.
 We need more happy lifestyles with each other
 Equality in the healthcare system
5. How do you learn about the health services available in our community?
 Postal services
 By using the services
6. Which community health resources, other than the hospital or clinic, have you used in the
last three years?
 Dr. Clary’s office (2)
 Walking trail
7. In your opinion, what would improve our community’s access to healthcare?
 Affordable (5)
 Better administration (2)
 Quality doctors
 A new hospital
 Less drama with doctor, nurses, and staff (3)
 Extended days of service outside of Shelby
 Not to lose so many doctors
 Honesty within the system
 Alternative Medicine
 Doctors that know their jobs
 Better hospital decisions
 Better primary care providers
 Home Health Care
 Getting to know the doctors will increase trust in doctors
 Access to doctors of your choice
 Totally new management. Trust is gone; local costs exorbitant
 Removal of Dr. Clary (4)
 Change CEO and CFO
 Allow Dr. Clary access to the ER (2)
59
8. If any of the following classes/programs were made available to the Shelby community, which
would you be most interested in attending?
 Dr. Clary’s office
 Financial/estate planning
 Alternative Medicine
 How to treat people fairly and with respect
10. Which of the following preventative services have you used in the past year?
 Diabetic test
 Lab for INR’s [International Normalized Ratio blood test]
 Sports Physical (2)
12. If yes, what were the three most important reasons why you did not receive healthcare
services?
 Did not feel I needed care
 Needed specialist
 Doctors change too often (2)
 No local provider
 Doctor canceled appointment
 Don’t like specific doctor on call (2)
 Couldn’t see my own doctor
 Management of clinic and hospital
 The hospital board should work for the people not their own likes or dislikes. The
hospital board got rid of a very well-liked doctor. The board should not be so judgmental,
and treat people fairly.
 Family doctor not allowed on premises (2)
 Main caregiver/doctor was fired (3)
 Do not want to support hospital under current administration
13. What additional healthcare services would you use if available locally?
 Dermatologist
 Endocrinology
 Alternative Medicine
 Allergist
 Reflexology
 Mental health
15. If yes, which hospital does your household use the MOST for hospital care?
 Depends on services needed
 Flathead Orthopedics
 Billings
 Out of state
 St. Patrick Hospital in Missoula, MT
 Lack of doctor with most patients unable to use the hospital
60
16. Thinking about the hospital you use most frequently, what are the three most important
reasons for selecting that hospital?
 Where services are available
 Doctor we chose
 Competent doctors
 Attention to service
 Services not available closer to home
 Specialist availability/care procedures not available locally
 Not comfortable with quality of local doctors
19. Where was that primary healthcare provider located?
 Dr. Clary (15)
 Private clinic in Great Falls, MT
 Sunburst, MT (2)
 Glacier Community Health Center (3)
 Private practice
 Marias Healthcare Services until they fired my doctor after he had given over 30 years of his
life [working at Marias Medical Center]
20. Why did you select that primary care provider?
 Dr. Clary’s knowledge and experience (7)
 Because he [primary care provider] had treated me since he came here [Marias Medical
Center]. He knows me inside and out. I trust him with my life.
 Nice people who actually acted like they cared
 Family Doctor (5)
 Costs in Shelby are too high
 Privacy concerns
 Only available specialist
 Experience with physician
 Doctor’s reputation (3)
 Our family physician (2)
 Woman
 Not Robert Clary
22. What type of healthcare specialist was seen?
 Seizure disorder specialist
 Hematologist
 Plastic surgeon (2)
 Rheumatologist
 Pain management
 Naturopath
 Cancer specialist (2)
Question 22 continued on following page…
61
Question 22 continued…








Kidney doctor
Ultrasound
Colonoscopy
Eye doctor (2)
Flight physician
Bladder infection
Anesthesiologist
Orthopedic surgeon
23. Where was the healthcare specialist seen?
 Phoenix, AZ
 Billings (5)
 Browning
 Chicago, IL
 Chester
28. If you do NOT have medical insurance, why?
 IHS [Indian Health Services]
Additional Comments:
 Will not do business with Marias Medical Center. “Screw them” after what they did to Dr. Clary.
 Marias Healthcare needs to be more competitive. Costs are too high here and billing is poor.
Doctors are “weird” and seem incompetent.
 I do not use any Shelby medical services because of the extremely poor medical service that is
available. The city of Shelby needs to look into programs to attract decent doctors. Right now we
get doctors that cannot get jobs anywhere else.
62
Appendix F – Focus Group Questions
Purpose: The purpose of the focus groups was to identify motives of local residents when selecting
healthcare providers and why people may leave the community to seek health services. This market
research will help determine the awareness of local programs and services, as well as satisfaction or
dissatisfaction with local services, providers, and facilities.
1. What would make this community a healthier place to live?
2. What do you think are the most important local healthcare issues? (Probe question: What do you
think are the biggest issues facing local healthcare services?)
3. We are now going to ask you for your views about the hospital. What do you think of the hospital
in terms of:
 Quality of care
 Number of services
 Hospital staff (style of care, competence)
 Hospital board and leadership (good leaders, trustworthy)
 Business office
 Condition of facility and equipment
 Financial health of the hospital
 Cost
 Office/clinic staff
 Availability
4. Are any of the local providers your personal provider or personal provider to your family
members? Why?
5. What do you think about these local services:
 Emergency Room
 Ambulance service
 Healthcare services for Senior Citizens
 Public/County Health Department
 Healthcare services for low-income individuals/families
 Nursing Home/Assisted Living Facility
 Pharmacy
6. Why might people leave the community for healthcare?
7. What other healthcare services are needed in the community?
63
Appendix G – Focus Group Notes
Focus Group #1
Tuesday, June 24, 2014 – 12pm-1pm – Marias Medical Center – Shelby, MT
12 participants (1 male, 11 female)
1. What would make this community a healthier place to live?
- Wellness programs
- Actual wellness programs…not just go get your blood drawn and computer-based
stuff. We [Marias Medical Center] do have some employer-based programs, but we
need local wellness programs. A lot of employers do no offer them.
- Yes, there are many small businesses that cannot afford to do that [offer
wellness programs for employees].
- We just lost our weight loss program, and we do not have any sort of Weight
Watchers programs here [in Shelby].
- What about that program the Physical Therapy Department [at Marias Medical
Center] was doing with the kids?
- We [Physical Therapy Department] didn’t do it this year. It was a speed
and agility program. The first time we did the program it was totally
free, and then we had to start charging $25 to cover the costs. This year
there just weren’t enough kids signed up.
- There are fitness classes at the Civic Center, but usually the hours are 9am to5pm and
are not compatible with most people’s work schedules.
- More opportunities for nontraditional active populations. Maybe something for kids
who aren’t typically active, not just sports, or for programs for seniors.
- Better fruits and vegetables, basically access to healthy food.
- Affordable healthy food
- Bio Tune Up [grocery store] used to try to have healthy food but no one was
going there.
- You can drive to Cut Bank and buy way better groceries.
- Connectedness. More and more people are talking about not feeling connected to the
community. People used to seek out more services, like joining a church, but now they
do not do as much.
2. What do you think are the most important local healthcare issues?
- Diabetes education would be nice, and cardiac rehab would be nice. People have to
drive long distances to seek these services.
- I think smoking is huge. I think it is huge in communities lacking wellness programs.
- We [Marias Medical Center staff] have tons of calls about people who aren’t ready to
go into assisted living, but they need home health care.
- There is a lot of that. We hear about it at the Public Health Department a lot,
too.
- Could the Senior Center offer services for them [elderly living in their homes]?
- I think there is a huge need for home health. There is an actual grant
funded through the Senior Center. The grant is for full-time caregivers
who need a little break. Someone will come into the home, do light
64
housekeeping, respite care, and other things to give the caretaker a
break.
3. What do you think of the hospital in terms of:
Quality of Care
- I think we [Marias Medical Center] are in crisis. We have had issues with a doctor that
has split us wide open.
- Even though there are outlying issues, our-day-to day care is great.
- I know from personal experience, from when my mom was here [Marias Medical
Center], she was not getting her medications on time, and she was staying at the
hospital because the Heritage Center [Assisted Living Facility] was booked. We had
an incident where one of the doctors was very inappropriate, and I asked him to leave
after I took her into the ER.
- I have never had any problem here [Marias Medical Center]. I get in, and I get my
stuff. I live in Valier and can even see the doctor once a week if I want, which is very
nice.
- I did take my son to the doctor, and he told my son to “buck up.” I thought that was
very insensitive. The bed-side manner here [at Marias Medical Center] could use some
improving.
- Confidentiality gets breached from some of the nursing staff. Someone from here
[Marias Medical Center] is talking about private stuff out in the community.
- The CNA was being nosy, just to be nosy.
- We [staff at Marias Medical Center] actually talked about that in a customer
service meeting.
- I think a lot of the gossip has been eliminated after they quit allowing smoking
on hospital grounds. They [staff] aren’t just gossiping away while smoking
anymore.
- Quality of care is great. We need quality physicians though. We are in a transition. I
think it is getting better than it previously was, but we don’t want quantity over
quality.
Number of Services
- I think for our size we [Marias Medical Center] offer a lot. We offer more than the
surrounding small hospitals.
- I think we are a leader in the field.
- It would be so nice to have Pediatric Care here.
- It would be awesome to have an orthopedic surgeon, but we are just dreaming
here.
- Yeah, cost of equipment is too pricey.
Hospital Staff
- Recruitment is so difficult for a rural hospital. It is difficult no matter what. We can’t
compete with Benefis [hospital in Great Falls] and cannot offer services competitively.
- Our staff must hold each other responsible.
- The staff doesn’t really work well together. But, that is a time thing, I think.
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I think for the most part we [Marias Medical Center staff] do okay! However, I
may see things differently.
We [Marias Medical Center] need more specialists. It’s hard as a nurse. We have to
wear many hats. When we are expected to do too many things it sets the standards too
high. It is really hard. I’m sure physicians feel the same way. [In a rural hospital] you
are expected to be an expert in every field. That is really hard.
- Could we [Marias Medical Center] get more physicians? I think it has been
discussed but I do not know what direction we are going.
Hospital Board and Leadership
- We [Marias Medical Center staff] are in transition. The board is also in transition.
- In regards to the new hospital board members, I appreciate that they are posting more
updates [for the public’s awareness].
Business Office
- I think they are really on top of it. We had a procedure done and bills were sent very
fast.
- The way hospitals are billed, and then reimbursed, is just difficult.
- Our billing department is doing things differently, things are changing.
- We [billing department] are auditing high dollar services. They are being
flagged and looked into.
- Should we advertise how we restructured our pricing?
- Distinguishing the difference between hospital and clinic bills is confusing.
- Patients must pay these separate. But they [patients] usually lump them
together.
- That is confusing. However, it is no different than what other places [clinics
and hospitals] do.
- Shelby Clinic bills are much easier to decipher.
Condition of Facility and Equipment
- I think it [condition of facility] has gotten better and better. Better than surrounding
areas anyways.
- Nursing home [Care Center] needs a little attention.
- Physical Therapy moved over here [Maris Medical Center], which is good.
- Customers liked PT [Physical Therapy] where it was before, but [now having]
more space is nice. Finding a parking spot is annoying for customers. And
coming up a ramp to enter the clinic is an issue.
- Some more visible signs would be nice for the PT [Physical Therapy] department. And
a ‘sign in’ [space] for the hospital and clinic. I think they [patients] get to the ER and
then stop. More signs would be nice.
- The Care Center could look a little nicer. Maybe someday they could get an OB
[Obstetrics services] room?
- I think the [hospital] layout makes it very hard to check-in. To even find a nurses
station is difficult. The layouts of the offices are difficult to navigate.
- We [Marias Medical Center] do not have a main desk. One central point is needed.
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Financial Health of the Hospital
- The community probably feels that it [financial health of the hospital] isn’t particularly
stable. They may also feel that it costs more compared to other places, like Billings.
Cost of care is perceived to be higher here.
Cost
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We [Marias Medical Center] have done adjustments [in lowering pricing for services],
and we are trying to work with each department.
When you consider driving [to a surrounding hospital], it’s more cost effective to
come here [Marias Medical Center] versus driving somewhere else and taking a whole
day off from work.
Office/Clinic Staff
- The admissions office has no privacy. They [patients] have to stand against the wall
[while waiting to check in]. You can hear the person checking people in.
- If you come here [Marias Medical Center] early [in the morning], a nurse will send
you to the lab, but do you stand or sit down? Where do I go? We need a waiting room.
You just stand there. It’s awkward. I felt like I was not supposed to be there. Should I
even be waiting?
- We [Marias Medical Center staff] don’t want that. But there is no true main
desk.
- As for privacy, should we give them [patients] a number? Utilize other waiting
areas and call over an intercom [when we are ready for them]?
Availability
- It is not hard to get an appointment.
- The dentist is difficult to get a hold of.
- [Dental services] are billed from the clinic.
- I do not choose to use services here [Marias Medical Center] because I know there are
privacy issues.
- We [Marias Medical Center] had to recruit a dentist for years. He [dentist] books about
three months in advance. And we [Marias Medical Center] are hiring a dental
hygienist.
- He [dentist] is awesome. If you are miserable, he gets you in. He is really good
in the ER. It cleans up the ER traffic. The equipment [used by the dentist] is
very nice. He [dentist] also does OR in the surgery center.
4. Are any of the local providers your personal provider or personal provider to your family
members? Why?
- I use Marias Medical Center most of the time but when I do seek care elsewhere it is
because the service is unavailable. We do not have a OBGYN here, and therefore you
must find it elsewhere
- We have one [OBGYN] who comes here.
- Yeah, but there was no OB when I needed it.
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5. What do you think about these local services:
Emergency Room
- Only good!
- Never had to use it [ER].
- Quick. All is good except the waiting room experience. It is too open. People can walk
in and watch. It is not private but the quality of care is great.
Ambulance Service
- Great!
- I wish we could have paramedics, speaking of dreams. For ACLS [Advanced
Cardiovascular Life Support] and other services, we need to call Conrad.
Healthcare Services for Senior Citizens
- I think we excel in this area [healthcare for seniors]. We have a rural Sunburst Clinic
that helps keep folks in their homes longer.
- We have life lines, transportation, and an assisted living center.
Public/County Health Department
- They [health department] are a valuable resource to use in the Clinic.
- They [health department] offered free screenings to woman, providing mammograms
and colonoscopies.
- I don’t think the community knows what all they offer, maybe they should
market more.
- We [Toole County Health Department] are perceived as the last resort call. I
wish people knew more about us.
Healthcare Services for Low-Income Individuals/Families
- The clinic has a sliding fee scale [for low-income patients]. The Health Department
has WIC [Women, Infants and Children] and [lower] immunization fees [available for
low-income patients].
- Hill Burton funds [Federal program that provides free and reduced cost healthcare] are
used up in four months. They [low-income patients] know to get in right away on July
1st [so they are eligible to receive funds before the funds are used up].
Nursing Home/Assisted Living Facility
- Heritage Center [Assisted Living Facility] fills up, so what can we do differently to
make our Care Center [Nursing Home] where patients want to stay?
- If you can stay at the Heritage Center as long as possible, that’s good. Not
many [patients] want to go to the nursing home.
- If you [as an elderly patient] do not have a family member to advocate for you,
you will not get good quality of care.
- I think it’s cultural. Nobody wants to go to a nursing home. If they can afford
the Heritage Center, that is certainly the [preferred] option. [Our aging
population holds] the old rancher mentality, [but there are] the safety issues [at
stake] which is why we need to educate [the public about] why these centers
exist!
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There has been a shift in the whole industry [long-term care]. Care is way too
expensive. They [family members] will keep them [person needing care] at home as
long as possible, which is much cheaper. When we [Care Center staff] finally get them
[patients], they are train wrecks. We do not have the funds to care for these highdemand patients.
AD [Alzheimer’s Disease] units are re-done, with locks, better floors and railings [in
the Care Center].
Pharmacy
- Two pharmacies are available in town.
- People use them [pharmacies] and seem to be happy.
- Nothing is available at night or on the weekend.
- But, the hospital gives a few pills to those people until pharmacy is open.
- They [local pharmacies] do a great job!
6. Why might people leave the community for healthcare?
- We do not have any planned parenthood or other services like that.
- They can come get a pregnancy test [at Marias Medical Center].
- Because Shelby is a small community, some care is just a bit too personal! Could you
imagine getting a colonoscopy from your neighbor?
- I know of two patients that have just recently gone to Great Falls to deliver their
babies because of the nurses in the hospital [at Marias Medical Center]. Both noted
that they love Dr. Hardy and will return for her care after their babies are born.
- A recent transition in providers has caused a lot of folks to choose other [care] options.
It is really split.
- I wonder if I am going to have to change physicians in 6 months. Developing a
relationship with a provider is challenging, and it is difficult during this current
transition of providers.
- Sometimes I think people just do not know what is fact or fiction. The gossip is
bad.
- OB [Obstetrics services] has been sought outside of the community.
- OB [Obstetrics services] is offered here [Marias Medical Center] now, but it
hadn’t been previously.
- I heard instruments were being dropped on the floor in the Operating Room,
[which created] a stigma that things were dirty [when performing Obstetric
services.]
- How do you know if that is true or not?
- I feel like any issue now has become a paramount issue. Everything seems
more negative than positive.
- It is affecting our [Marias Medical Center] volunteers. They are
either on one side or the other. We need more volunteerism, and a
sense of community.
7. What other healthcare services are needed in the community?
- Having a Health Fair is really important. It provides education to the public, which is
great! It also teaches us [community members] about the hospital.
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Focus Group #2
Tuesday, June 24, 2014 – 6pm-7:45pm – Marias Medical Center – Shelby, MT
4 participants (1 male, 3 female)
1. What would make this community a healthier place to live?
- To make our hospital healthier, because right now it is not. I think we are working on
that. There are a lot of people outside the hospital that I feel are almost like a poison.
A group of them [community members] want the CEO to fail. This group has been
super crude to the CEO and his family, and for those who are against keeping this
doctor. Community members have lost business, it’s getting insane. I have lived here
most of my life, minus ten years, I have raised three kids here and am really proud of
this town, but I am not proud right now.
- It’s not just outside of this community, but also inside the hospital. There have
been staff members here who have gotten shunned.
- I think there is a poison within this building that needs to be eliminated. It is
keeping our facility from growing.
- We [Shelby community] are getting a lot of negative perceptions from the
surrounding communities.
- I think this hospital is spot on. We are working on physical fitness, getting new doctors
and we are spot on where a lot of rural hospitals are not. But there is a big road block.
- Trying to get people to recognize how important preventative care is. People must
exercise, get their blood work checked. I guess trying to get better awareness about
what they [community members] can do to help themselves. We should teach them to
recognize what they can do to help themselves before they get sick.
2. What do you think are the most important local healthcare issues?
- Prescription drug abuse
- Teen drinking and selling too much over-the-counter medications, causing abuse.
- I do think there is a drug problem, but I think it is in all these little towns, not
just Shelby.
- Mental health services and parenting is a real problem. There are a lot of issues with
parents not providing good care to their kids, nutritionally and prenatally.
- Tobacco and alcohol within the youth. Mental health is a big issue which affects
physical health for the whole family.
3. What do you think of the hospital in terms of:
Quality of Care
- Personally, I would rate it [quality of care] pretty high.
- Four years ago my colon ruptured and the ER was great. They sent me to Great Falls.
Just for them [Marias Medical Center ER staff] to react so quickly, they have a
physician who comes in off-site who is wonderful. Even the regular doctors are great.
The radiology department is great too.
- I hear good things, the only negative is that Dr. Clary could be here all day and now he
can’t. But the quality of care is good.
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There has been a big turnover in help [staff at Marias Medical Center] and in a little
community, people do not like that. That makes it tough to give it 100% when
turnover is high.
I’ve seen both extremes. I was an EMT for 22 years. I have been all over the state.
There were times when I transported patients here [Shelby] and have worried about the
care the providers were providing. On the other hand, there have been times when I
have been upset with other hospitals. I convinced the people in Billings to take my
mother here [Marias Medical Center], and she got wonderful quality of care here. I’ve
seen both extremes as a provider and user. Overall, given the remoteness, it’s
phenomenal.
Number of Services
- I think it [services available] is pretty good. We [Marias Medical Center] have a big
helicopter, just in case something goes wrong. We also have a lot of specialty doctors
who come in.
- As long as it is cost effective, we [Marias Medical Center] can do it [medical
procedures].
- The services are appropriate for the size of the facility. Some [facilities] do not have
the advanced specialty care, but that is expected. [The services are] very adequate for
where we are. We chose to live here, and therefore we chose to not have all those
specialists.
Hospital Staff
- Usually I do not hear about the actual care. Most people rate care very high no matter
what department it is.
- Other than once or twice depending on the ER doctor, I have never had a problem
[with hospital staff].
- There are negative perceptions about Marias Medical Center in the community right
now and incorrect information has been shared, particularly on the radio recently.
- We had two traumas, and the care delivered was great. Thirty to forty kids were in an
accident, and in the end we [Marias Medical Center] treated over 20 patients.
Everyone came together and we all got through it. We [staff] react well and pull
together. Also some outside agencies helped out. I felt a great sense of community
after that trauma.
Hospital Board and Leadership
- The CEO is wonderful. I’m sure he won’t be here much longer because he is so good.
The hospital board has no leadership. They cannot even control their own meetings.
When they [hospital board] think about trying to keep this facility up and running it
makes me sick.
- I used to trust our [hospital] board about six months ago, when everything used to
seem like it was on track but after the recent provider transitions, a few [hospital]
board members moved [away from Shelby] and I feel like no one knows the new ones
[hospital board members]. The new ones [hospital board members] have gone in a new
direction, the CFO has resigned, and I cannot even call the new board members, so
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who can I call to ask? Who is going to lead us and guide us? Where will we [Marias
Medical Center] be in a month?
I think they [hospital board] are not making the best decisions. The board members
have an agenda.
- And the sad thing is, is that they [hospital board] are very public about this. To
the point that even our local pharmacy is affected. No one is friendly. No one
wanted to wait on me [at the local pharmacy] because now they [pharmacy
staff] know exactly what side of the recent transition of providers I am on. The
pharmacist is very involved in this transition. I think the pharmacist has not
distinguished business from personal life.
- That is why we need an active hospital board committee. I do not feel
comfortable asking them [hospital board] what is going on.
- As an employee [at Marias Medical Center], you do not feel like they are
protecting you.
- Is the [hospital] board looking at the big picture? No. There is no support.
- They [hospital board] are making their decisions based off emotions. The
county commissioners can override whatever decision they do. That makes me
feel a little safer, so we must trust the county commissioner.
- The [hospital] board consists of all volunteers. When a big issue comes up,
they need to have more personal involvement. They [hospital board members]
only know what they hear from the board meetings. Those are their only
perceptions [what they hear in the hospital board meetings].
I have never dealt with them [hospital board]. I felt bad when certain staff felt he had
to resign because of everything that was going on. I know what it feels like when the
public wrongly accuses board members of doing something they didn’t.
Business Office
- [Community members are] probably not happy with the Billing Department. They
[community members] do not understand what is going on with the billing department.
- When doctors take a long time to dictate, it influences the billing process.
- People may not understand the [billing] statements.
- We [Marias Medical Center] are overpriced, but we have started to reduce the prices
of some things.
Condition of Facility and Equipment
- I think they [Marias Medical Center staff] are always working on it [condition of the
facility]. Our Auxiliary has added a lot to the rooms. The nurses will come visit with
us [Auxiliary] and tell us what they need. So we [Auxiliary] work on a budget and try
to get them [nurses] what they ask for. We just bought two new items for the Physical
Therapy Department. I think Mark [CEO at Marias Medical Center] does a fabulous
job.
- The landscape is really nice, we repainted the parking lot.
- The donations and Auxiliary donations are nice.
- There are limitations on staff [at Marias Medical Center]. Our maintenance is also our
ambulance volunteers.
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They [ambulance volunteers] get pulled in so many directions. Sometimes that
is why there is a delay in receiving services.
The hospital is in great shape for a rural medical center.
Financial Health of the Hospital
- It [financial health of the hospital] is bad from what I know. And I’m sure I do not see
the whole picture. I see what we need for payroll, but the months that you do not hit
payroll, the county has helped our hospital. Financially, it is a huge concern.
- EMR [Electronic Medical Records] was just a huge hit financially, and we are still
working on that, for over two years now.
Cost
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A lot of people in the community say that cost of care is high.
- I always tell them that our [Marias Medical Center] costs are no different from
costs down the road.
- We have reduced ambulance, radiology, and lab charges, and I’m hoping that
will eliminate the negative perceptions [about cost].
Everyone compares us [Marias Medical Center] to Great Falls, but that is not realistic.
[The cost of care is] no different than anywhere else. It is outrageous. They have to
charge that much in order to pay for those who do not pay. Dropping prices will not
change this country-wide crisis.
Office/Clinic Staff
- I have never heard a negative thing about checking in here [Marias Medical Center].
- A friend of ours from Canada got a bloody nose, he came in here, and the girl at the
front desk asked about 40 questions. He thought she asked too many questions, instead
of providing care in a timely manner.
- There are so many questions that we [staff] are required to ask right now, it is a
bit ridiculous and it is hard to get through it quickly.
- They [staff] talk so loud when you check in! As you are talking to them [check-in
staff], there is no privacy. You can hear everything!
- When they [check-in staff] repeat things to clarify, such as social security numbers and
all sorts of personal information, everyone else can hear, and there is no privacy.
- Check-in staff are welcoming. No problems.
Availability
- I think it [availability of services] goes through streaks. The clinic tries to keep a few
openings per day.
- I have never had any problems [getting an appointment].
- Quick and effective.
- It’s okay. I recognize that when there is an ambulance, sometimes you need to pull
people from another job.
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4. Are any of the local providers your personal provider or personal provider to your family
members? Why?
- Yes. The only reason we would leave the area is for specialty care. My son did his
physical therapy here [Marias Medical Center]. We support what is here.
- I choose local providers to support my local community. I went to Great Falls to see
my old provider who was bullied out of here [Marias Medical Center] and now she
practices in Great Falls.
- The drive gets old. But just when I think I’ll try one of the physicians here [Marias
Medical Center], they [physicians] seem to rotate out and a new one comes along. But
supporting the new ones [physicians] are better than driving elsewhere.
- I know we have good staff. I can trust whoever is on call. I don’t care about the
personal difference. I want care here [at Marias Medical Center].
5. What do you think about these local services:
Emergency Room
- Pretty good services. If someone comes in with an agenda and the provider doesn’t
follow through, it makes them [patients] mad. When it is a true emergency the
providers do whatever is necessary.
- The time I came in they [Marias Medical Center ER staff] were absolutely wonderful.
Very time effective, they did an awesome job.
- Tough at times, depending on the time of the day. They [Marias Medical Center ER]
know when the crew is coming in via EMS [Emergency Medical Service], so why is
there a delay? If we [EMS] are coming from Sunburst I wish the MD would be waiting
for us. The timelines would have been nice to have. If we [EMS] tell them [ER] what
we need in advance, you would think there is a quicker response. From a professional
stand point, they [ER] should take us [EMS] more seriously.
Ambulance Service
- Great!
- The level of care is right there with any other rural agency. The training they
[ambulance crew] receive is as good as they come.
- I think our ambulance crew is awesome. They are always training, and our volunteer
Auxiliary [Marias Medical Center Auxiliary club] is always giving them money and
they are putting those funds to great use.
Healthcare Services for Senior Citizens
- There is a physical fitness program for seniors, which is nice.
- The ER offers free blood pressure screenings for everybody. Many seniors take
advantage of that.
- The Heritage Center is an extended care facility.
- Do they have programs for any seniors not staying there?
- They are financially under the hospital, all bundled together with the same tax
ID number.
- I am curious about home healthcare options because that is something I need
personally.
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Public/County Health Department
- I think she [public health nurse] does great. I think they are busy and do well.
- I think they [health department] are always trying to expand and educate.
- They [health department] are easy to work with. The collaboration is wonderful.
- I always wonder what they [health department] do. They formed a ReACT group
[Montana youth advocating against tobacco use], but I’m not too sure what else. They
deal with WIC [Women Infants Children] but I have never had a need to interact with
them.
Healthcare Services for Low-Income Individuals/Families
- I do not know.
- Clinic is FQHC [Federally Qualified Health Center], with a sliding fee scale. The
hospital has Hill Burton funds [Federal program that provides free and reduced cost
healthcare], which you can also apply for.
- We have people [Marias Medical Center staff] who help them [low-income
families] with Healthy Montana kids, who basically fill out the application for
them.
- They [Marias Medical Center] will not turn you away from services no matter
what.
- There is a very short form that we [Marias Medical Center staff] can fill out
that allows coverage for 30 days through Medicaid. We [Marias Medical
Center staff] are certified to do that. It depends on your income, so we approve
it if it falls below a certain level. That way, the facility doesn’t have to pay for
that [care received by patients who cannot pay their bill].
Nursing Home/Assisted Living Facility
- The Heritage Center [assisted living facility] is wonderful.
- As for the Care Center [nursing home] side, when people call you rarely hear
complaints.
- We [Care Center staff] do Patient Satisfaction Reports with residents and their
families. They [residents] have care plan options for family and all that. The
Care Center is our nursing home, which is a part of our hospital. It is a licensed
facility with 65 beds.
- They [Care Center] have an AD [Alzheimer’s Disease] wing, and I’ve heard lots of
great things.
- We [Care Center] just got a $14,000 new tub! It accommodates seniors better.
- I have heard nothing but positive things. The care my mother received was
phenomenal. Everyone was great for her. As far as people I know with family
members at the Heritage Center [assisted living facility], all was positive.
Pharmacy
- I think they [pharmacists] do amazing things. She [pharmacist] delivers [medications]
to people who are home bound. Shopko will do some deliveries too. I think she
[pharmacist] picks and chooses who she wants to deliver to. She [pharmacist] stopped
delivering to me, so I pulled my account and went to Shopko.
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It’s been great. Anna [pharmacist] is unbelievable to work with, really good and easy
to work with.
The pharmacist is very involved in this provider transition.
6. Why might people leave the community for healthcare?
- Because of the high emotion revolving around this doctor [at Marias Medical Center].
If we [community members] had an effective [hospital] board then that would have
been taken care of. If we could just send him [doctor] on his way it would solve a lot
of problems.
- We go out of town for pediatric care because we don’t expect to have that service here
[Marias Medical Center].
- Some people have followed providers who now practice in Great Falls, and some
providers went to [work in] Conrad.
- Because of all the misinformation and what they [community members] perceived has
gone on with the [hospital] board, employees, and doctors. People see all of that and
just want to go elsewhere. I found the provider to be very knowledgeable, but his
personal relationships have spilled over. Community members do not like that.
7. What other healthcare services are needed in the community?
- It is important to bring young families back to Shelby. My daughter-in-law is very
interested in this facility [Marias Medical Center] and she doesn’t want to have babies
with providers in Great Falls. We want to make these little towns grow! That is what
happens in rural towns. This hospital needs to correlate with the rest of the growing
buildings in Shelby. I want OB [Obstetrics] resources, and the Auxiliary is very
supportive of that. None of our [Marias Medical Center] staff have their babies here
[Marias Medical Center]. I think that is really sad. People say not to have their babies
here [at Marias Medical Center]. Do they not trust them [Marias Medical Center staff]
enough to have their babies? There were a couple incidents, one resulting in the loss of
a child. Because of confidentiality issues, we [community members] do not know what
is true.
- One of the problems facing all of rural Montana is the lack of volunteerism needed to
keep EMS [Emergency Medical Services] alive. After over two decades of service, I
was forced to retire due to inflexible rules established by Toole County EMS that
mandated that I could only miss two meetings per year; meetings that always occurred
on the first Thursday of every month. This worked out for me most of the time, but
due to other obligations, I ended up in a situation this past year where I missed more
than two meetings. Everywhere else I’ve served as an EMT [Emergency Medical
Technician] have understood that I had a very busy schedule and were willing to work
with me to take what time I could give, but the inflexibility of the EMS administration
in Toole County resulted in me having to give it up after 22 years. As it is now, we
have no EMT serving in Sunburst and the only two left in the northern part of the
County have to drive quite a distance, and this certainly affects patient care.
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Focus Group #3
Wednesday, June 25, 2014 – 12:15pm-1pm – Senior Center – Shelby, MT
25 participants (12 male, 13 female)
1. What would make this community a healthier place to live?
- I’ve felt pretty healthy all of my life, until all these politics and [hospital] boards came
into play.
- The feedlot smells.
- Maybe they [Shelby community workers] should fumigate the sewage system.
- If everyone could live in harmony, the whole community would benefit.
- Yeah, take the politics out!
2. What do you think are the most important local healthcare issues?
- Nutrition
- Good people to get back to the Senior Center.
- It’s hard to get people to volunteer.
- We keep losing our doctors.
- It is very difficult getting people to volunteer anywhere, including the hospital and the
Senior Center.
3. What do you think of the hospital in terms of:
Quality of Care
- Very good
- Good
Number of Services
- Exceptional. They [Marias Medical Center] have specialists who come in once a
month.
Hospital Staff
- The crew is only as good as the leader.
- [Hospital staff] are nice and provide good care.
- There are administrative problems.
- Nurses do not get paid enough.
- The comments from [hospital] board meetings that are broadcasted over the public
radio are skewed and the information is not correct.
Hospital Board and Leadership
- I think they [Marias Medical Center’s hospital board] have a big job to do, and I think
sometimes they are not awarded for what services they put in.
- They [hospital board] have a tough job.
- We tried to ask all these questions to our board members, and they wouldn’t answer
because they said it was none of our business. Yet our tax dollars are paying for it and
no one answers our questions. We cannot get an answer out of them [board members]!
I feel that there is a big issue with our community and their leadership.
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There needs to be better communication between the [hospital] board and the
community.
The community has no input.
- They [hospital board] need to improve communication with the community.
Business Office
- Billing [department] is bad and late.
- When I get a bill from six months later from Medicare, I approach Medicare, not the
billing office.
- There is a lot of miscommunication between Medicare and the hospital.
- The billing department is not great.
Condition of Facility and Equipment
- The upkeep [of the facility] is okay.
Financial Health of the Hospital
- I do not know [about the financial health of the hospital].
- They [Marias Medical Center] want 400-some thousand dollars.
- I heard that they [Marias Medical Center] were in the hole last year.
- Hill Burton funds [Federal program that provides free and reduced cost healthcare]
and Medicaid helped pay my bills.
- If they [Marias Medical Center] keep losing patients, they will go broke.
- They [Marias Medical Center] have lost a lot of patients over the last year.
Cost
-
[Costs are] pretty high.
- Higher than Great Falls.
- Higher than most places.
Office/Clinic Staff
- Good
- They [office and clinic staff] do fine.
Availability
- It [availability of services and appointments] is okay.
4. Are any of the local providers your personal provider or personal provider to your family
members? Why?
- Yes. My family uses Shelby [Marias Medical Center].
- My family left because my doctor moved!
- We left because of all the turmoil [at Marias Medical Center].
- Doctors [at Marias Medical Center] seem to be leaving so people [patients] leave too.
It’s hard to see a doctor, and then they [doctors] leave. The turnover rate makes it
difficult.
- It’s hard to travel out of town. Most people try to stay because of that.
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5. What do you think about these local services:
Emergency Room
- Never used it [ER]!
- It [ER] has been okay.
- It [ER] was good when I broke my hip.
Ambulance Service
- Good ambulance personnel.
- Very rough ambulance ride.
- That isn’t their [ambulance service] fault – it’s the rough roads!
Healthcare Services for Senior Citizens
- I’m basically well, so things [services for seniors] are fine.
- Okay.
Public/County Health Department
- Good!
- The hospital would be healthier if they sold local food.
- Don’t know much [about the health department].
- Never used them [the health department].
Healthcare Services for Low-Income Individuals/Families
- Veteran services could be improved nationally.
- Obama is going to fix that [Veteran health services]!
- Medicaid takes care of patients.
- These types of people [low-income individuals/families] are living better than me!
Obama takes too good of care of them!
- I haven’t heard anything.
Nursing Home/Assisted Living Facility
- The Heritage Center [assisted living facility] is nice.
- I have heard complaints but that’s it.
- They [Care Center staff] take care of people the best they can.
- They [Care Center staff] seem to get residents out and take them on trips. They treat
them [residents] well.
- They do not have enough nurses for the nursing home.
Pharmacy
- They [pharmacies] are adequate.
- So good.
6. Why might people leave the community for healthcare?
- When you have something seriously wrong, you have to go elsewhere. My wife has
RA [rheumatoid arthritis] and we have to leave for infusion treatments.
- I wish the doctors [at Maris Medical Center] would stick around a bit longer.
- Doctors leaving [Marias Medical Center] makes us [local patients] leave.
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-
Doctors [at Marias Medical Center] are moving all the time.
Leadership is bad here [at Marias Medical Center].
- It [leadership] is not going to change, therefore I leave.
- Yeah, there is too much bullying.
- Leadership [at Marais Medical Center] must change!
- But the city and county work well together.
- No they don’t.
- It is split.
- But we have a record of all the projects they’ve worked together on.
- Each side must treat each other with respect.
7. What other healthcare services are needed in the community?
- I wish we could have them all, but that’s not realistic.
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Appendix H – Secondary Data
County Profile
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Economic Impact Assessment
Demographic Trends and Economic Impacts:
A Report for Marias Medical Center
William Connell
Brad Eldredge Ph.D.
Research and Analysis Bureau
Montana Department of Labor and Industry
Introduction
This report responds to requests by MHA for the location quotient of the hospital sector in
Toole County and for information on the county’s demographics. In addition, the report includes
analysis of the economic impact of the hospital sector on Toole County’s economy. Section I gives
location quotients for the hospital sector in Toole County using both state and national employment
as the basis of comparison. Section II looks at the demographic profile of Toole County. Section III
presents the results of an input-output analysis of the impact of Marias Medical Center on the
county’s economy.
Section I Location Quotients
A location quotient measures how the level of employment concentration in a geographic area
compares with that of another geographic area. For example, if 20 percent of workers in county A
worked in manufacturing and 10 percent of the workers in that county’s state worked in
manufacturing, then the location quotient for county A would be:
County A Percent employed in manufacturing = 20% = 2.
State Percent employed in manufacturing
10%
Intuitively, county A’s location quotient of 2 indicates that its employment in manufacturing is about
double what one would expect given the size of manufacturing employment in the state.
Two location quotients for hospital employment in Toole County were calculated. The first
compares Toole County’s hospital employment concentration to that of the State of Montana, and the
second compares it to hospital employment in the United States. The calculations use 2010 annual
averages.
Hospitals Location Quotient (compared to State of MT) = 1.74
Hospitals Location Quotient (compared to U.S.) = 2.01
A location quotient near 1 indicates that the employment concentration in the county mirrors
that of the larger geographic region. In the case of Toole County, the location quotient of 1.74
indicates that hospital employment in the county about 75 percent higher than one would expect
given statewide employment patterns. When compared to the nation, the location quotient is an even
higher 2.01. Toole County probably has such high location quotients because staffing a full-service
hospital requires a base number of employees regardless of the overall population of the county.
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Many rural hospitals have high location quotients because, unlike their urban counterparts, they
cannot take advantage of economies of scale.
Another way to look at the location quotient is to ask how many employees would be
employed in the hospital sector if Toole County’s employment patterns mirrored the state or the
nation. Marias Medical Center averaged 191 employees in 2010. This is 81 more than expected given
the state’s employment pattern and 96 more than expected given the national employment pattern. In
2010, Marias Medical Center accounted for 9.3% of county nonfarm employment and 8.7% of the
county’s total wages.
(Source of Employment Data: Quarterly Census of Employment and Wages, Research and Analysis Bureau, Montana
Department of Labor and Industry)
Section II Age Demographics
The 2010 Census reported that there were 5,324 residents of Toole County. The breakdown of these
residents by age is presented in Figure 1. Toole County’s age profile is similar to that of many of
Montana’s rural counties. In 2010, baby boomers were between the ages of 44 and 60 and their
presence is evident in the graph. Following the baby boom came the “baby bust,” which is evidenced
by the lack of 25 to 44 year olds in the county. In many rural Montana counties, the baby bust is
exacerbated by out-migration of young adults.
Figure 1: Age Distribution of Toole County Residents
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Figure 2: Percent of the population by age groups, Toole County vs. Montana
Figure 2 shows how Toole County’s population distribution compares to Montana’s. A careful
examination of Figure 2 and the underlying data reveals that, compared with the State as a whole,
Toole County has a much higher percentage of people aged 30 to 59 (45.0 percent vs. 40.2 percent)
and a lower percentage of children under 10 (10.2 percent vs. 12.4 percent). Overall, the county and
state age profiles are very similar. According to the 2010 Census, Toole County had a median age of
41.5, which was slightly higher than the state median age of 39.8. These demographics are important
when planning for healthcare delivery now, and in the future.
Section III Economic Impacts
Businesses have an economic impact on their local communities that exceeds the direct
amount of people they employ or wages they pay. For example, individuals employed at Marias
Medical Center spend a portion of their salary on goods and services produced in Toole County, thus
supporting jobs and income in those local businesses. Likewise, the hospital itself may purchase
goods and services from local suppliers. These businesses and employees then spend a portion of
their income on local goods and services which, in turn, supports other local jobs and companies.
Thus, the effect of one dollar of wages is multiplied as it circulates through the community.
The amount of jobs and income in a local community attributable to a particular industry
sector can be determined by calculating its employment and income multipliers. Industries with the
highest multipliers generally are those who buy supplies, services, and labor from the local
community, sell products and services outside the local community, and pay a high income to their
employees. Although hospitals in rural areas do not usually sell their services to non-residents, they
can still generate significant multiplier effects for their communities given that much of their funding
comes from outside the region in the form of public and private insurance reimbursements. The
relatively high wages earned by hospital employees also tend to boost hospital’s multipliers.
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Multipliers are calculated using a methodology called input-output modeling. The Research
and Analysis Bureau (R&A) uses IMPLAN software to do regional input-output modeling. The R&A
staff is able to correct the underlying IMPLAN data with confidential employment and earnings data
from the unemployment insurance system, which allows us to produce more accurate multipliers than
would otherwise be possible.
According to the input-output analysis, the hospital industry sector in Toole County has the
following multipliers:
Hospital Employment Multiplier = 1.49
Hospital Employee Compensation Multiplier = 1.63
Hospital Output Multiplier = 1.27
What do these numbers mean? The employment multiplier of 1.49 can be interpreted to mean that for
every job at Marias Medical Center, another .49 jobs are supported in Toole County. Another way to
look at this is that if Marias Medical Center suddenly went away, about 94 additional non-hospital
jobs would also be lost in the county (based on 2010 hospital employment of 191). The employee
compensation multiplier of 1.63 simply states that for every dollar in wages and benefits paid to the
hospital’s employees, another 63 cents of wages and benefits are created in other local jobs in Toole
County. Put another way, if Marias Medical Center suddenly went away, about $3,896,417 in
additional annual wages would be lost from other jobs in the county. Finally, the output multiplier
indicates that for every dollar of goods and services produced by Marias Medical Center, output in
the county increases by another 27 cents.
There are other potential economic impacts of hospitals beyond those identified by the inputoutput analysis. Novak (2003)1 observes that “…a good healthcare system is an important indication
of an area’s quality of life. Healthcare, like education, is important to people and businesses when
deciding where to locate” (pg. 1). Thus, all other things being equal, the presence of a quality
healthcare system gives communities an advantage when competing for new businesses. An effective
healthcare system can also attract retirees to the community. Finally, healthcare may provide an
opportunity for young people to stay in the communities where they were raised and still earn a high
wage. In areas of the state where economic opportunities are scarce, many hospitals are experiencing
shortages of qualified workers. In this situation, “growing your own” workforce may be a viable
option.
This study has sought to outline the economic importance of Marias Medical Center to the
county’s economy. Tangible economic impacts have been presented, and intangible economic
development impacts have also been discussed. Any questions regarding the data or methodology can
be addressed to the author.
Novak, Nancy L. (2003) “Bridging the Gap in Rural Healthcare” The Main Street Economist: Commentary on the Rural
Economy, Center for the Study of Rural America: Federal Reserve Bank of Kansas City. September 2003
1
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