Community Health Assessment of Ridgeway County: Identifying Uninsured Adults Aged 45 to 64 as the Priority Population
Student Name
American College of Education
NUR4043: Community Health and Vulnerable Populations
Module 4 Assignment
Instructor Name
April 6, 2025
Community Boundary and Data Sources
This assessment covers Ridgeway County, a composite Midwestern county of 148,000 residents written for teaching, so no real county, agency, employer, or resident is described here. The boundary was drawn at the county line rather than at a home health service area, because the datasets that carry the indicators below are published at county and census tract level, and a boundary that does not match the published data produces rates nobody can check. Inside that line, 12 census tracts were treated as the working sub-areas. Two of them, written here as Tract 12 and Tract 14, hold 19,400 residents between them, which is 13.1 percent of the county population.
Four data sources carry the numbers, and each one is named with its collection period so a reader can tell how old the picture is. Population, income, and coverage figures come from American Community Survey 5-year estimates covering 2018 through 2022 (U.S. Census Bureau, 2023). Chronic disease prevalence comes from model-based small-area estimates published for 2022 (Centers for Disease Control and Prevention, 2024). Preventable hospital use follows the ambulatory care sensitive conditions definition in the national prevention quality indicator set (Agency for Healthcare Research and Quality, 2023). The weighting of clinical care against social and economic factors follows the County Health Rankings model (County Health Rankings & Roadmaps, 2024). Vital statistics are pooled across five years, because annual counts in a county this size swing too far to read.
Population Profile and Health Indicators
Ridgeway County holds 148,000 residents. Of these, 32,560, or 22.0 percent, are aged 65 and over, and 26,300, or 17.8 percent, are under 18. Adults aged 45 to 64 number 38,500. Median household income across 2018-2022 is $54,900, and 18.4 percent of residents, which is 27,232 people, live below the federal poverty threshold. Health services inside the county consist of one 96-bed hospital, four primary care clinics, and a federally qualified health center that opens its dental suite three days out of seven. None of those sites sit inside Tract 12 or Tract 14, a fact that becomes load bearing later in this assessment.
Coverage is where the county separates from itself. Countywide, 11.2 percent of residents under 65, which is 12,930 of 115,440 people, had no health coverage across 2018-2022. In Tract 12 and Tract 14 the same measure reaches 24.6 percent. Among adults aged 45 to 64 living in those two tracts, 1,260 of 5,120 people were uninsured, and that single figure carries more of this assessment than any other number in it. The Healthy People 2030 objective of increasing the proportion of people with health insurance frames why the gap matters rather than only how wide it is (Office of Disease Prevention and Health Promotion, n.d.).
Diagnosed diabetes among adults aged 18 and over stands at 12.6 percent countywide for 2022, against a modeled state figure of 10.1 percent for the same period. High blood pressure reaches 36.2 percent of adults in that estimate. Preventable hospital stays run at 4,120 per 100,000 Medicare enrollees for 2021. Emergency department visits for conditions a clinic could treat run at 168 per 1,000 residents aged 45 to 64 in Tract 12 and Tract 14 across the 12 months ending December 2023, against 61 per 1,000 for the same age band elsewhere in the county. Every rate above is written with the population it divides by and the period it covers, because a rate without both is a rumor.
Two further indicators were pulled because they are often assumed rather than measured. Infant mortality across the pooled years 2019-2023 is 8.1 deaths per 1,000 live births, or 121 deaths among 14,900 births, and the pooled count is used because a single year in a county this size moves too much to interpret. Births to females aged 15 to 19 run at 28.4 per 1,000 across 2016-2022. Neither indicator concentrates in Tract 12 or Tract 14; both sit within a point of the county figure. That is still a finding, because it tells the assessment where the problem is not.
Which Population the Data Selects
The staff conversation that began this assessment named older adults as the priority, and the reasoning was not careless: 22.0 percent of the county is 65 and over, hospital admissions are dominated by that group, and every nurse in the room had a recent case in mind. Disaggregating by age band and tract does not support the conclusion. Residents aged 65 and over hold near-universal coverage through Medicare, their preventable stay rate is high but tracks the state figure rather than exceeding it, and their attachment to a primary care clinic is the strongest of any age band in the county. Age selected them. The data did not.
The population the data selects is uninsured adults aged 45 to 64 in Tract 12 and Tract 14, which is 1,260 people out of the 5,120 in that age band and those tracts. Three separate measures converge on them. Their uninsured share is 24.6 percent against 11.2 percent countywide, their emergency department use for conditions a clinic could treat is 168 per 1,000 against 61 per 1,000 for the same ages elsewhere, and diabetes and high blood pressure estimates for both tracts sit above county figures while no primary care site stands inside either boundary. Convergence is what turns a number into a finding; one measure alone would only have raised a question.
Vulnerability here is a structural position rather than a personal characteristic, and writing it that way changes what the plan is allowed to do. This group is not at risk through motivation or ignorance. It is at risk because coverage, transport, and clinic hours line up badly for people working daytime shifts without paid leave, many of them earning too much for public coverage in jobs that offer none, a combination the coverage data makes visible without naming a single employer. That reading matches the County Health Rankings model, which sets clinical care beside social and economic factors rather than above them (County Health Rankings & Roadmaps, 2024). A plan built to teach this group about diabetes would miss the finding entirely.
Community Nursing Diagnosis and Targeted Plan
The community nursing diagnosis is written in the risk, population, and evidence form used in community health nursing texts (Rector & Stanley, 2022). Risk of uncontrolled chronic disease among uninsured adults aged 45 to 64 in Tract 12 and Tract 14, related to absent coverage and to the absence of any primary care site inside those tracts, as evidenced by an uninsured share of 24.6 percent against 11.2 percent countywide across 2018-2022, emergency department use of 168 per 1,000 for conditions treatable in a clinic across the 12 months ending December 2023, and adult diabetes prevalence above the county figure of 12.6 percent in both tracts for 2022.
The intervention is a nurse-run evening screening and enrollment clinic in the Tract 12 community center, open two evenings out of seven from 1700 to 2000, staffed by two registered nurses and one certified enrollment counselor. The offer is deliberately narrow: blood pressure, a point-of-care A1C, and a coverage eligibility check, because a small service that runs on schedule beats a broad one that opens and closes. The location was chosen for a bus line running until 2130 and for hours that fit daytime shifts, which is the access barrier the data identified, rather than the knowledge gap the original conversation assumed.
Evaluation rests on three measures, each with a fixed denominator. First, adults enrolled in coverage as a share of those screened and found eligible, reported monthly for 12 months. Second, the share of screened adults with a blood pressure at or above 140/90 mm Hg who attend a primary care visit within 60 days. Third, emergency department visits for conditions treatable in a clinic among residents aged 45 to 64 in the two tracts, measured against the baseline of 168 per 1,000 after four full quarters. No outcome is claimed for this plan. The assessment states what was measured, which population the measurements select, and what would count as a change.
References
Agency for Healthcare Research and Quality. (2023). AHRQ quality indicators: Prevention quality indicators. https://qualityindicators.ahrq.gov/
Centers for Disease Control and Prevention. (2024). PLACES: Local data for better health. https://www.cdc.gov/places/
County Health Rankings & Roadmaps. (2024). County health rankings model. University of Wisconsin Population Health Institute. https://www.countyhealthrankings.org/
Office of Disease Prevention and Health Promotion. (n.d.). Health care access and quality. Healthy People 2030. U.S. Department of Health and Human Services. Retrieved March 2, 2025, from https://health.gov/healthypeople/objectives-and-measures/browse-objectives/health-care-access-and-quality
Rector, C., & Stanley, M. J. (2022). Community and public health nursing: Promoting the public's health (10th ed.). Wolters Kluwer.
U.S. Census Bureau. (2023). American Community Survey 5-year estimates: 2018-2022. https://data.census.gov/
How this NUR 4043 Module 4 example is structured
In many sections this NUR4043 Module 4 assignment in Community Health and Vulnerable Populations asks for an assessment of one defined community ending in a community nursing diagnosis and a targeted plan; your course instructions and rubric decide the exact form. This example is built so a reader can audit it. The first section sets the boundary and names every data source with its collection period, before any figure appears. The second section reports the indicators, each one carrying its denominator and window. The third section is the argument: it states the population staff assumed was most at risk, then shows the three measures that select a different group. The last section converts that finding into a nursing diagnosis, an intervention aimed at the barrier the data found, and measures with fixed denominators.
NUR4043 Module 4 questions, answered
What does NUR4043 Module 4 usually ask for?
American College of Education does not publish deliverable names module by module, so treat this as the common shape rather than a fixed name. In many sections a Module 4 assignment in Community Health and Vulnerable Populations asks for an assessment of one defined community that ends in a community nursing diagnosis and a targeted plan. Your course instructions and rubric decide the exact form.
How do I identify a vulnerable population from data instead of assuming one?
Break the county into age bands and tracts, then look for measures that converge. One high number raises a question; three pointing at the same group supports a claim. State the population your colleagues assumed was most at risk, test it, and report honestly when the figures send you somewhere else. That refusal is usually the strongest paragraph in the paper.
Can I use a composite community instead of a real county?
Either works if you are honest about which you used. Label a composite once, in the opening paragraph, and keep the national sources and definitions real. What a rubric checks is not the county name but whether every rate carries its denominator and time window, whether the sources are named with collection periods, and whether the plan follows the finding.
Write yours, or have the desk draft it
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