20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination.docx
D517 Population Health Coordination
Task 3: Population Health Improvement Plan
12/31/2024
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
, 20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination.docx
Target Patient Population Profile and Healthcare Risks
Coahoma County is situated in the northwest region of Mississippi, bordered to the west by the
Mississippi River, which links the county to Arkansas. The county is predominantly agricultural,
with a population of approximately 21,000 people. According to the U.S. Census Bureau, 78% of
the population identifies as Black or African American, and 53% of residents are female.
Approximately 36.3% of the population lives below the poverty line, with 57% of children living
in poverty being Black or African American. Additionally, 40% of residents have less than a high
school education.
The county’s households are nearly evenly divided between renters and homeowners. Data
from the U.S. Census Bureau (2018-2022) reveals that 57% of households are headed by single
parents, over 64% of families are maintained by unmarried grandparents, 12.5% of
grandparents are responsible for raising grandchildren, and more than 38% of these
grandparents remain active in the workforce.
Mississippi has one of the highest maternal mortality rates in the United States (USAFacts,
2023). According to the World Health Organization, maternal mortality is defined as the death
of a female during or following pregnancy, and the Centers for Disease Control and Prevention
(CDC) reports that “more than 80% of pregnancy-related deaths are preventable.” A significant
proportion of maternal deaths occur between one week and one year postpartum. In Coahoma
County, U.S. Census Bureau data shows that in the last 12 months, there were 323 births, of
which 230 were to unmarried mothers and 209 were to Black or African American mothers.
In response to these statistics, the Population Health Improvement Plan aims to reduce
maternal mortality in Coahoma County, with a focus on the priority population of unmarried,
Black, pregnant women.
Social determinants of health in Coahoma County, such as poverty, food insecurity, and
unstable housing, significantly impact residents’ ability to prioritize and maintain their health.
These factors are particularly challenging for single-parent households, teenage pregnancies,
and grandparents raising grandchildren, all of whom face unique difficulties that can negatively
affect maternal health and access to necessary care.
Coahoma County also encounters multiple barriers to healthcare access, contributing to poor
health outcomes, including high maternal mortality rates. Key barriers include:
• Geographic Isolation: The county's rural nature makes it difficult for residents to access
healthcare services, particularly prenatal and post-pregnancy care. The lack of nearby
healthcare facilities and specialists increases the challenges for individuals who need
specialized maternal care.
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
, 20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination.docx
• Shortage of Healthcare Providers: There is a significant shortage of healthcare providers
and specialists in the county, limiting access to quality care for pregnant women and
those needing maternal health services.
• Economic Barriers: With a large portion of the population living below the poverty line,
many residents struggle to afford healthcare, including necessary prenatal visits,
medications, and treatments. Furthermore, Mississippi’s limited expansion of Medicaid
exacerbates these financial barriers, leaving many without sufficient coverage.
• Transportation Challenges: Many residents face difficulties in accessing healthcare
facilities due to a lack of reliable transportation options, which can result in missed
prenatal and post-pregnancy appointments, further compromising health outcomes.
• Health Literacy: A significant portion of Coahoma County’s population has limited
educational attainment, which can hinder understanding of key health information. This
lack of health literacy often makes it difficult for individuals to recognize the importance
of prenatal and follow-up care, leading to delays in seeking medical attention.
• Limited Maternal Health Programs: The county lacks comprehensive maternal health
programs, such as prenatal education, breastfeeding support, and mental health
services, which are essential for supporting maternal well-being during and after
pregnancy. The absence of these resources can leave women without the support they
need to maintain good health throughout pregnancy and beyond.
Addressing these barriers and social determinants of health is crucial to improving maternal
health outcomes in Coahoma County and ensuring that all residents have access to the care and
resources they need for a healthy pregnancy and postpartum recovery.
Coahoma County has four hospitals within a 30-mile radius, providing residents with options for
medical care. In addition to these hospitals, primary care clinics in the area offer basic
healthcare services, including family medicine and general health screenings. However, these
clinics often have limited hours and capacity, which can affect access to care. The county is also
served by a local health department that offers some maternal health programs, such as the
Women, Infants, and Children (WIC) program, though these services are often underfunded and
limited in scope. The area's federally Qualified Health Centers (FQHCs) provide low-cost
healthcare, including prenatal care, but they are frequently overwhelmed by high demand.
Additionally, Coahoma County has a School-Based Clinic in Clarksdale and healthcare services
available to students through Coahoma Community College. Emergency medical services are
accessible in the county, but delays in response times can occur due to their rural nature, and
the cost of emergency care can be prohibitively high. Mental health services, particularly for
conditions like postpartum depression, are critically limited in Coahoma County, making it
difficult for residents to access necessary support for maternal mental health.
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
D517 Population Health Coordination
Task 3: Population Health Improvement Plan
12/31/2024
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
, 20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination.docx
Target Patient Population Profile and Healthcare Risks
Coahoma County is situated in the northwest region of Mississippi, bordered to the west by the
Mississippi River, which links the county to Arkansas. The county is predominantly agricultural,
with a population of approximately 21,000 people. According to the U.S. Census Bureau, 78% of
the population identifies as Black or African American, and 53% of residents are female.
Approximately 36.3% of the population lives below the poverty line, with 57% of children living
in poverty being Black or African American. Additionally, 40% of residents have less than a high
school education.
The county’s households are nearly evenly divided between renters and homeowners. Data
from the U.S. Census Bureau (2018-2022) reveals that 57% of households are headed by single
parents, over 64% of families are maintained by unmarried grandparents, 12.5% of
grandparents are responsible for raising grandchildren, and more than 38% of these
grandparents remain active in the workforce.
Mississippi has one of the highest maternal mortality rates in the United States (USAFacts,
2023). According to the World Health Organization, maternal mortality is defined as the death
of a female during or following pregnancy, and the Centers for Disease Control and Prevention
(CDC) reports that “more than 80% of pregnancy-related deaths are preventable.” A significant
proportion of maternal deaths occur between one week and one year postpartum. In Coahoma
County, U.S. Census Bureau data shows that in the last 12 months, there were 323 births, of
which 230 were to unmarried mothers and 209 were to Black or African American mothers.
In response to these statistics, the Population Health Improvement Plan aims to reduce
maternal mortality in Coahoma County, with a focus on the priority population of unmarried,
Black, pregnant women.
Social determinants of health in Coahoma County, such as poverty, food insecurity, and
unstable housing, significantly impact residents’ ability to prioritize and maintain their health.
These factors are particularly challenging for single-parent households, teenage pregnancies,
and grandparents raising grandchildren, all of whom face unique difficulties that can negatively
affect maternal health and access to necessary care.
Coahoma County also encounters multiple barriers to healthcare access, contributing to poor
health outcomes, including high maternal mortality rates. Key barriers include:
• Geographic Isolation: The county's rural nature makes it difficult for residents to access
healthcare services, particularly prenatal and post-pregnancy care. The lack of nearby
healthcare facilities and specialists increases the challenges for individuals who need
specialized maternal care.
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
, 20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination.docx
• Shortage of Healthcare Providers: There is a significant shortage of healthcare providers
and specialists in the county, limiting access to quality care for pregnant women and
those needing maternal health services.
• Economic Barriers: With a large portion of the population living below the poverty line,
many residents struggle to afford healthcare, including necessary prenatal visits,
medications, and treatments. Furthermore, Mississippi’s limited expansion of Medicaid
exacerbates these financial barriers, leaving many without sufficient coverage.
• Transportation Challenges: Many residents face difficulties in accessing healthcare
facilities due to a lack of reliable transportation options, which can result in missed
prenatal and post-pregnancy appointments, further compromising health outcomes.
• Health Literacy: A significant portion of Coahoma County’s population has limited
educational attainment, which can hinder understanding of key health information. This
lack of health literacy often makes it difficult for individuals to recognize the importance
of prenatal and follow-up care, leading to delays in seeking medical attention.
• Limited Maternal Health Programs: The county lacks comprehensive maternal health
programs, such as prenatal education, breastfeeding support, and mental health
services, which are essential for supporting maternal well-being during and after
pregnancy. The absence of these resources can leave women without the support they
need to maintain good health throughout pregnancy and beyond.
Addressing these barriers and social determinants of health is crucial to improving maternal
health outcomes in Coahoma County and ensuring that all residents have access to the care and
resources they need for a healthy pregnancy and postpartum recovery.
Coahoma County has four hospitals within a 30-mile radius, providing residents with options for
medical care. In addition to these hospitals, primary care clinics in the area offer basic
healthcare services, including family medicine and general health screenings. However, these
clinics often have limited hours and capacity, which can affect access to care. The county is also
served by a local health department that offers some maternal health programs, such as the
Women, Infants, and Children (WIC) program, though these services are often underfunded and
limited in scope. The area's federally Qualified Health Centers (FQHCs) provide low-cost
healthcare, including prenatal care, but they are frequently overwhelmed by high demand.
Additionally, Coahoma County has a School-Based Clinic in Clarksdale and healthcare services
available to students through Coahoma Community College. Emergency medical services are
accessible in the county, but delays in response times can occur due to their rural nature, and
the cost of emergency care can be prohibitively high. Mental health services, particularly for
conditions like postpartum depression, are critically limited in Coahoma County, making it
difficult for residents to access necessary support for maternal mental health.
20250101033627_6774b83b5aac6_d517_task_2_population_health_coordination
