SUSAN G. KOMEN MINNESOTA

Transcription

1 SUSAN G. KOMEN MINNESOTA

2 Table of Contents Table of Contents... 2 Acknowledgments... 3 Executive Summary... 5 Introduction to the Community Profile Report... 5 Quantitative Data: Measuring Breast Cancer Impact in Local Communities... 6 Health System and Public Policy Analysis... 7 Qualitative Data: Ensuring Community Input... 8 Mission Action Plan Introduction Affiliate History Affiliate Organizational Structure Affiliate Service Area Purpose of the Community Profile Report Quantitative Data: Measuring Breast Cancer Impact in Local Communities Quantitative Data Exploration Selection of Target Communities Health Systems and Public Policy Analysis Health Systems Analysis Data Sources Health Systems Overview Public Policy Overview Health Systems and Public Policy Analysis Findings Qualitative Data: Ensuring Community Input Qualitative Data Sources and Methodology Overview Qualitative Data Overview Qualitative Data Findings Mission Action Plan Breast Health and Breast Cancer Findings of the Target Communities Mission Action Plan References P age

3 Acknowledgments The Community Profile Report could not have been accomplished without the exceptional work, effort, time and commitment from many people involved in the process. would like to extend its deepest gratitude to the Board of Directors and the following individuals who participated on the 2015 Community Profile Team: Denise Blumberg-Tendle Director of Mission Initiatives Susan G. Komen Minnesota James A. Chase, MHA President MN Community Measurement David Egan Co-Executive Director Susan G. Komen Minnesota Matt Flory, MPP State Health Systems Account Representative American Cancer Society Jerri Hiniker, BSN, RN, CPHQ, CPEHR Program Manager Stratis Health Jane Korn, MD, MPH Medical Director Health Promotion & Chronic Disease Division Minnesota Department of Health Barb Kunz, MS, CGC Cancer Genetic Counselor Humphrey Cancer Center of North Memorial Shelly Madigan, MPH Sage Programs Section Manager Minnesota Department of Health 3 P age

4 Elizabeth Moe, MPH Senior Program Evaluator Center for Prevention Blue Cross and Blue Shield of Minnesota Dan Mueller, PhD Consulting Scientist Wilder Research Char Plitman Co-Executive Director Susan G. Komen Minnesota Darcie Thomsen, MSW Research Scientist Wilder Research Patrick Tschida, MPH, DrPH Principal Epidemiologist Minnesota Cancer Surveillance System Minnesota Department of Health A special thank you to the following entities for their assistance with data collection and analyses, as well as providing information included in this report: Wilder Research Minnesota Department of Health Report Prepared by: Wilder Research 960 Southdale Center 451 Lexington Parkway North Edina, MN Saint Paul, MN Contact: Denise Blumberg-Tendle Contact: Darcie Thomsen 4 P age

5 Introduction to the Community Profile Report Executive Summary plays a special role in Susan G. Komen s vision of creating a world without breast cancer. They partner with local organizations to strive to ensure that all people, regardless of race, income, geographic location, sexual orientation or insurance status have access to screening, and if diagnosed, to quality, effective treatment and treatment support services. Susan G. Komen Minnesota engages in fundraising activities, including Susan G. Komen Twin Cities Race for the Cure and Susan G. Komen Brainerd Lakes Race for the Cure, which provide millions of dollars in programming and awareness projects throughout the state. Since its inception in 1993, the Affiliate has raised nearly $50 million, which has been awarded to Minnesota institutions for breast cancer awareness, education, outreach, screening, preliminary treatment, treatment support and research. In 2014, the Affiliate awarded $1,090,524 to 17 grantees. The Affiliate covers a large service area, including each of Minnesota s 87 counties, and more than five million people. More than half of the total population of the state is concentrated in the Twin Cities seven-county metro area. Purpose of the Community Profile Report Affiliates, including Susan G. Komen Minnesota, were asked to conduct a comprehensive Community Profile. The Community Profile will help Susan G. Komen Minnesota align its community outreach, grantmaking and public policy activities towards the same mission goal. The Purpose of the Community Profile Report is to: Align strategic and operational plans Drive inclusion efforts in the community Drive public policy efforts Establish focused granting priorities Establish focused education needs Establish directions for marketing and outreach Strengthen sponsorship and partnership efforts The Affiliate contracted with Wilder Research to coordinate this effort. Along with Affiliate staff, a community advisory team was convened with representatives from the American Cancer Society, the Minnesota Department of Health, MN Community Measurement, Stratis Health, the Humphrey Cancer Center of North Memorial, Blue Cross and Blue Shield of Minnesota s Center for Prevention, and members of the Board of Directors of the Affiliate. The advisory committee convened regularly throughout the assessment process, and was instrumental in guiding the selection of targeted communities, framing research questions for the Profile, and establishing recommendations for Affiliate priorities. Wilder s role was to facilitate the process, help identify target areas, conduct data collection and analysis, prepare the Community Profile Report, and help to guide Affiliate staff and the advisory committee through consideration of results and setting priorities. Affiliate staff and the advisory committee were involved at each decision point 5 P age

6 and provided recommendations and insight to each of the tools and/or approaches that was used for this project. Quantitative Data: Measuring Breast Cancer Impact in Local Communities Susan G. Komen Minnesota has chosen five target communities within the service area. The Affiliate will focus strategic efforts on these target communities over the course of the next four years. When selecting target communities, the Affiliate reviewed Healthy People 2020, a major federal government initiative that provides specific health objectives for communities and the country as a whole. HP2020 has several cancer-related objectives, including: Reducing women s death rate from breast cancer (Target: 20.6 per 100,000 women). Reducing the number of breast cancers that are found at a late-stage (Target: 41.0 cases per 100,000 women). Specific to Komen Minnesota s work, goals around reducing women s death rate from breast cancer and reducing the number of breast cancers found at a late-stage were analyzed for the entire state. Through this review, areas of priority were identified based on the time needed to meet Healthy People 2020 targets for breast cancer. To examine these data for the entire state, counties were first grouped by Community Health Board (CHB) areas. Community Health Boards provide public health infrastructure for all 87 Minnesota counties. The goal of examining breast cancer statistical data by CHB areas was to get a more complete picture of the quantitative data related to breast cancer by reducing the proportion of the Affiliate s service area for which data needed to be suppressed due to small numbers. Overall rates and trends for late-stage incidence and deaths from breast cancer were calculated for each Community Health Board area in Minnesota. These rates and trends were then used to calculate the time needed to achieve Healthy People 2020 goals for late-stage incidence and breast cancer death rates. Classification of priority areas are based on the time needed to achieve HP2020 targets in each Community Health Board area. These time projections depend on both the starting point and the trends in death rates and late-stage incidence rates. To see how well CHB areas in the Komen Minnesota service area are progressing toward the HP2020 targets, the report uses the following information: CHB area breast cancer death rate for years 2006 through 2010 and late-stage diagnosis rate for years 2005 through 2009, the most recent available data. Estimates for the trend (annual percent change) in CHB area breast cancer death rates used data for years 1988 through 2010 and late-stage diagnoses used data for years 1995 through Annual percentage change for each CHB was calculated following the methods used in the Quantitative Data Report. Additional key indicators the Affiliate reviewed when selecting target counties included, but were not limited to: Incidence rates and trends Death rates and trends 6 P age

7 Late-stage incidence rates and trends Screening percentages Percentage of residents living in a rural area Percentage of residents who are American Indian/Alaska Native Percentage of female residents who are over 40, over 50, and over 65 The selected target communities are: Faribault-Martin Community Health Board and Freeborn County area, which encompasses Faribault, Martin, and Freeborn Counties in Minnesota. These counties have been chosen because the estimated time to achieve HP2020 targets for the death rate and late-stage incidence rate are 13 years or more and 14 years or more, respectively. Kanabec-Pine Community Health Board area, which encompasses Kanabec and Pine Counties in Minnesota. This area has been chosen because the estimated time to achieve HP2020 targets for the death rate and late-stage incidence rate are 13 years or more and 14 years or more, respectively. Fillmore-Houston Community Health Board area, which encompasses Fillmore and Houston Counties in Minnesota. This area has been chosen because the estimated time to achieve HP2020 targets for the late-stage incidence rate is 14 years or more, and for the death rate, eight years. Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board area, which encompasses Lincoln, Lyon, Murray, Pipestone, Redwood, and Rock Counties in Minnesota. These counties have been chosen because the estimated time to achieve HP2020 targets is eight years for the death rate and 14 or more years for the late-stage incidence rate. Washington County, Minnesota. This county was chosen because the estimated time to achieve the HP2020 targets is eight years for the death rate and 14 or more years for the late-stage incidence rate. Health System and Public Policy Analysis Health System Analysis The Health System Analysis component of the Community Profile assessed the availability of services and resources in the identified target areas. Sites included in data collection were sites where mammography services were available, identified through the US Food and Drug Administration Mammography Facility Database, and sites identified as Sage (Minnesota s Breast and Cervical Cancer Control Program) providers. The Profile team developed a 25-item close-ended survey. Clinics and hospitals were given the option of completing the survey by telephone or electronically. A total of 81 clinics and hospitals were identified within the five target areas; 74 clinics and hospitals completed the survey over the phone or electronically. Partially completed surveys were collected from an additional two sites. Five clinics/hospitals were unable or unwilling to complete a survey despite numerous attempts to contact them. In addition to the telephone and electronic surveys, the Community Profile Team also identified resources for cancer patients and their caregivers in the target areas using the American Cancer Society website. The website includes a public registry of available services and resources throughout Minnesota. While not specific to breast cancer, the site provides services 7 P age

8 that could be utilized by many breast cancer patients, including but not limited to: financial assistance, prosthetics, legal assistance, symptom management, support groups, and end of life care. Findings were examined geographically by target community. Based on information gathered through providers, the Affiliate learned that resources in the five target communities vary. Access to mammography was somewhat limited in several rural communities, including the Faribault-Martin-Freeborn and Kanabec-Pine regions. There were fewer resources in most communities for treatment. For example, the Kanabec-Pine region had only one facility that offers any treatment services. Residents in the four rural target communities, Fillmore-Houston, Faribault-Martin-Freeborn, Kanabec-Pine, and SWHHS, may need to travel outside of their communities for treatment services. Few facilities across all five targeted communities noted that they provide transportation services for screening or treatment. In general, support services were also somewhat limited, especially in the rural areas. Susan G. Komen Minnesota found that many providers in the target areas provide women with breast self-exam training. This is a practice that Susan G. Komen does not support. Rather, Susan G. Komen supports a more holistic approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is normal for the individual, and making healthy lifestyle choices. These findings provide the Affiliate with an opportunity to partner with local health care providers in the target communities to provide Komen s breast self-awareness messaging through educational opportunities. The Affiliate also has several grantees that serve portions of the five targeted communities, including the Minnesota Department of Health Sage Screening Program, Cancer Legal Line, Gundersen Medical Foundation, and Allina Associated Foundation. The Affiliate has identified local health care providers in each targeted community as potential new partners. Public Policy Activities Susan G. Komen Minnesota collaborates with several partners, including the Minnesota Cancer Alliance and the American Cancer Society, to pursue public policy related goals. The local office of the American Cancer Society provides particularly strong leadership for public policy action in Minnesota. The Affiliate has a long-standing collaborative relationship with the American Cancer Society, and provides them with support on public policy activities. For example, the Affiliate s Director of Mission Initiatives has lobbied alongside the Vice President, Government Relations Midwest, American Cancer Society Cancer Action Network, Inc. to state legislators for the purpose of protecting funding for the Sage Screening Program. The Affiliate plans to continue its strong partnerships with the Minnesota Cancer Alliance, the American Cancer Society, the Minnesota Department of Health, and others to pursue public policy goals. One issue for future public policy action includes continued advocacy for the Sage Screening Program, to ensure all Minnesota women have access to breast cancer screening. Qualitative Data: Ensuring Community Input The qualitative data component of the Community Profile assessed the availability of services and resources, and further explored the gaps in services and barriers to seeking services for specific populations within the identified target areas. Key informant interviews were conducted with a number of stakeholders within each target community, including community members 8 P age

9 and volunteers, clinicians, public health nurses and coordinators, and hospital administrators. Key informant interviews consisted of 24 semi-structured interview questions. Trained interview staff at Wilder Research conducted a total of 49 interviews with stakeholders in the identified target areas, including interviews with nine survivors in the five target areas. Several needs and resources identified in the key informant interviews were common across the five target communities. Each community also had its own unique strengths and challenges related to breast health. In general, most key informants from the five target communities noted that awareness of breast health was high in their communities. Transportation was noted as a barrier to screening, diagnosis, and treatment services in the four rural target communities, which includes the Faribault-Martin-Freeborn, Fillmore- Houston, Kanabec-Pine, and SWHHS Community Health Board areas. Access to treatment and specialty care was also noted as a challenge in the four rural target communities, which includes the Faribault-Martin-Freeborn, Fillmore-Houston, Kanabec-Pine, and SWHHS Community Health Board areas. Each community identified subpopulations that may be less likely to receive screening services. Communities with greater ethnic diversity noted that women of some racial/ethnic identities (for example, American Indian women) may be less likely to receive screening than White women. Several communities identified poverty and being uninsured or underinsured as barriers to screening, diagnosis, and treatment. Two communities are home to populations of women who may not receive screenings due to religious preferences. Most of the target communities noted a preference for personalized outreach. In addition to key informant interviews, several documents related to breast cancer services and resources in Minnesota were reviewed, including documents from the Minnesota Department of Health, American Cancer Society, and the Minnesota Cancer Alliance. The Affiliate reviewed findings from the documents and the key informant interviews and tried to identify common themes across both qualitative methods. Few common themes emerged across the key informant interviews and document review. However, notable findings drawn from both sources are: Financial barriers were noted as challenges in most target communities. This aligns with one of the key breast cancer objectives outlined in the Minnesota Cancer Alliance s Cancer Plan Minnesota. This objective is to reduce financial barriers to breast cancer screening. Cancer Plan Minnesota is an updated framework for action created by the partners of the Minnesota Cancer Alliance to address the substantial burden of cancer in Minnesota. This framework is consistent with national priorities released in 2010 by the Centers for Disease Control and Prevention and by Healthy People Susan G. Komen Minnesota is currently a member of the Minnesota Cancer Alliance, and plans to continue its active role in the Alliance throughout the next four years. The Affiliate continues to focus on reducing financial barriers to breast cancer screening through its grant program and its support of the Sage Screening Program. 9 P age

10 Minnesota Community Measurement s 2013 Health Disparities Report noted a disparity between breast cancer screening percentages for women insured by Medicaid and other publically funded health insurance programs (60 percent) compared with women insured by private health insurance plans (73 percent). Key informants in several target communities also noted that low-income women may be less likely to be screened for breast cancer. The Minnesota Cancer Alliance s Cancer Plan Minnesota also outlines an objective around targeted outreach for breast cancer awareness, which includes small media campaigns and one-on-one outreach. Key informants in several target communities noted a preference for one-on-one outreach activities. Mission Action Plan Based on the findings of this Community Profile, Susan G. Komen Minnesota will work with partners and stakeholders to execute a Mission Action Plan which will aid them in developing or supporting population appropriate breast health programs to close gaps and address deficiencies as outlined in the report. It should be noted that the Affiliate will continue to support communities throughout Minnesota, in addition to those prioritized in this report. Key needs in the target communities, and the Affiliate s priorities and objectives related to these needs are described below: Need Statement 1: There is variability in breast cancer screening percentages among subpopulations of women in Minnesota. Data from Minnesota Community Measurement indicates that women enrolled in publicly funded insurance programs are less likely to be screened for breast cancer than women enrolled in privately funded insurance programs. Furthermore, key informants in each of the five target communities noted specific subpopulations in their communities they thought were less likely to be screened than others. However, quantitative data on screening percentages of subpopulations of women within the target communities was not available for the Community Profile Report. The Affiliate has developed the following priorities and objectives in response to this need: Priority Area 1: Identify subgroups of women within each of the five target areas with lower screening percentages. Explore potential explanatory factors for these differences. The Affiliate developed this priority in order to learn more about which specific subgroups of women are less likely to be screened, and to identify reasons for these disparities. The Affiliate has the following objectives related to this priority: Objective I: By fiscal year 2017, the Affiliate will examine Minnesota Community Measurement data to learn more about disparities in screening percentages in each of the five target communities. Minnesota Community Measurement data includes screening percentages for medical centers and clinics of large health systems throughout the state. Examining this data will be useful to the Affiliate in identifying subpopulations with lower screening percentages in target communities and potentially providing clues for why the percentages are lower. Objective II: By fiscal year 2017, disseminate findings from the exploration of Minnesota Community Measurement data. This may include disseminating findings to 10 P age

11 health systems, local providers in the five target communities, and others to educate stakeholders about variability in breast cancer screening percentages. Priority area 2: Develop and implement strategies to improve screening percentages in the identified subgroups in each of the five target communities. The Affiliate developed this priority in order to create an action plan that responds to what is learned from the Minnesota Community Measurement data. The Affiliate has the following objectives related to this priority: Objective I: By fiscal year 2018, create an action plan to improve screening percentages among subpopulations of women in each of the five target communities who are less likely to be screened, based on the findings from Minnesota Community Measurement data and other relevant information (e.g., research evidence for what works to increase screening percentages). Objective II: By fiscal year 2019, carry out the action plan that will be developed in fiscal year This may include collaborating with local stakeholders and partners, such as the American Cancer Society, Minnesota Department of Health, and local partners in each of the five target communities. Need Statement 2: Navigating the breast health system of care can be difficult for women in the Kanabec-Pine, Washington County, and SWHHS Community Health Board areas. Key informants in these target areas noted that it may be difficult for women in their communities to navigate the system of care, and noted a need for improved patient navigation. The Affiliate has developed the following priorities and objectives related to this need: Priority area 1: Identify challenges in the Kanabec-Pine, Washington County, and SWHHS areas that make it difficult for women to navigate the system of care. While each of these three target areas noted challenges with patient navigation, the Affiliate developed this priority to learn more about the specific challenges in each area. Further identifying specific challenges in each target community will allow the Affiliate to align resources with the most pressing needs in each community. The Affiliate has the following objectives related to this priority: Objective I: By Fiscal Year 2017, the Affiliate will share findings from the Community Profile with at least two providers in each of the three target areas of Kanabec-Pine, Washington and SWHHS Counties in order to raise awareness of the need for patient navigation services in their communities. Objective II: By Fiscal Year 2018, the Affiliate will partner with health systems in each of the three target areas of Kanabec-Pine, Washington and SWHHS Counties to identify specific navigation challenges for their patient populations. Priority area 2: Increase patient navigation services in the Kanabec-Pine, Washington County, and SWHHS areas. The Affiliate chose this priority because patient navigation can support patient care at all stages of the breast health continuum, improve the patient experience, and reduce barriers to care. The Affiliate has developed the following objectives related to this priority: 11 P age

12 Objective I: By Fiscal Year 2017, the Affiliate will identify at least one partner in each of the three target communities of Kanabec-Pine, Washington and SWHHS Counties who have an interest in improving patient navigation services. These partners will be encouraged to apply for grant funding to improve their patient navigation services. Objective II: By Fiscal Year 2018, the Affiliate intends to fund partners through its community grants program to improve patient navigation services in Kanabec-Pine, Washington and SWHHS Counties. Need Statement 3: There is a need for a more comprehensive, evidence-based approach to breast health education at some sites within each of the five target communities. In order to increase the use of these best practices for breast health education, the Affiliate has chosen the following priorities and objectives related to this need: Priority area 1: Identify which hospitals, clinics, community and/or nonprofit organizations in each of the five target communities could benefit from a more comprehensive, evidence-based approach to breast health education. The Affiliate is aware of the breast health education practices of each of the clinics that completed the provider survey, but needs to learn more about the sites that did not complete provider surveys. The Affiliate has the following objective related to this priority: Objective I: By Fiscal Year 2017, the Affiliate will reach out to the sites within each of the five target communities that did not complete the provider survey to learn about their current breast health education practices. Priority area 2: Increase the use of evidence-based breast health education in each of the five target communities. The Affiliate chose this priority so that more women in the target communities would have access to breast health education that aligns with the most recent best-practices recommendations. The Affiliate has the following objectives related to this priority: Objective I: By Fiscal year 2017, the Affiliate will partner with two hospitals, clinics, community and/or nonprofit organizations in each of the five target communities and provide resources and training on the most current Susan G. Komen breast health education model. Objective II: By Fiscal Year 2018, the Affiliate will partner with at least two clinics in each of the five target communities to update their practices around comprehensive breast health education. Disclaimer: Comprehensive data for the Executive Summary can be found in the 2015 Susan G. Komen Minnesota Community Profile Report. 12 P age

13 Introduction Affiliate History plays a special role in Susan G. Komen s vision of creating a world without breast cancer. They partner with local organizations to strive to ensure that all people, regardless of race, income, geographic location, sexual orientation or insurance status have access to screening, and if diagnosed, to quality, effective treatment and treatment support services. While many great advancements have been made over the last several decades in understanding the causes of breast cancer, how it behaves in the body, and successful treatments, there are many people who still do not have access to regular mammograms or quality breast cancer treatment. Susan G. Komen remains committed to fulfilling their promise to save lives and end breast cancer forever through empowering people, ensuring quality care for all, and energizing science to find the cures. Komen is focused on reducing breast cancer incidence and death within the next decade with increased emphasis on finding solutions for disparities in breast cancer across populations. Susan G. Komen Minnesota engages in fundraising activities, including Susan G. Komen Twin Cities Race for the Cure and Susan G. Komen Brainerd Lakes Race for the Cure, which provides millions of dollars in programming and awareness projects throughout the state. Since its inception in 1993, the Affiliate has raised nearly $50 million, which has been awarded to Minnesota institutions for breast cancer awareness, education, outreach, screening, preliminary treatment, and research. In 2014, the Affiliate awarded $1,090,524 to 17 Grantees. Up to 75 percent of the net funds donated to the Affiliate remain in Minnesota to cover every step of the breast cancer journey from education, outreach, mammograms and diagnostics, to pro bono legal care, meal preparation and delivery, and providing critical financial support to help with rent/mortgage payments, groceries, phone/utility payments and fuel. The remaining 25 percent of each net dollar donated funds international research. In fact, next to the US government, Susan G. Komen is the largest funder of breast cancer research in the world. A Komen grant has touched every major breast cancer breakthrough since Susan G. Komen Minnesota is a leader and expert in breast health and breast cancer in Minnesota. The Affiliate has a long-standing, collaborative relationship with Minnesota s Breast and Cervical Cancer Control Program, known as the Sage Screening Program. The Affiliate has provided financial support for Sage since 1993, and supplements the program from $250,000 - $1,000,000 annually. Sage administrators noted that the program would not be able to sustain its current level of outreach and screening without the continued support of the Affiliate. In addition, the Affiliate s Director of Mission Initiatives has served on the Minnesota Cancer Alliance s Steering and Evaluation Committees and Breast Health Network. Komen Minnesota is also one of five organizations (Minnesota Department of Health, Minnesota Genetic Counselors Association, FORCE, Minnesota Ovarian Cancer Alliance, and Susan G. Komen Minnesota) that make up a coalition that created the SuperYou public awareness campaign that aims to increase awareness and action around hereditary breast and ovarian cancer among people at elevated risk. 13 P age

14 Additionally, the Affiliate partners with the Breast Cancer Education Association on their annual October educational conference to provide cutting edge information about breast health and a broad range of healing philosophies and possibilities, from surgical options and the latest updates in oncology to mind, body, and spirit practices. Affiliate Organizational Structure The Affiliate employs four staff, including two Co-Executive Directors, Operations Director, and Director of Events and Mission Initiatives. The Board of Directors is a governing board that advises, assists, and aids in the Affiliate s efforts to support breast cancer research, education, screening and treatment through several active committees, including grants, finance, fund development, race, volunteer, and survivor committees (Figure 1.1) Affiliate Service Area Figure 1.1. Susan G. Komen Minnesota Organizational Structure The Affiliate covers a large service area, including each of Minnesota s 87 counties, and more than five million people (Figure 1.2). More than half of the total population of the state is concentrated in the Twin Cities seven-county metro area. Minnesota is undergoing some major demographic shifts which may impact the Affiliate s current and future activities. These changes include: While Minnesota is still not nearly as racially diverse as the nation, it is becoming more diverse. Over 18 percent of Minnesota residents are now persons of color, compared to only about one percent in Minnesota s population is aging. By 2030, the number of Minnesotans over age 65 is expected to almost double and older adults will comprise about one-fifth of the state s population. 14 P age

15 Minnesota is one of only two states in the nation to see a drop in poverty rates from 2011 to After three consecutive years of increases, Minnesota s poverty rate showed a statistically significant decrease from 11.9 percent in 2011 to 11.4 percent in However, at 27.0 percent, the poverty rate among Minnesotans of color is high. Poverty rates are especially high among certain groups, including African-Americans (38.0 percent), American Indians (32.0 percent), and Hispanics/Latinos (26.0 percent). Overall, Minnesotans are highly educated. In 2011, 32.0 percent of Minnesotans (age 25+) had a bachelor s degree or higher, compared with 29.0 percent of the nation overall. Over the next 30 years, high population growth rates are expected in exurban counties, those counties surrounding urban areas, throughout the state. However, counties in the Twin Cities region are expected to remain Minnesota s most populous. Minnesota is a geographically large state, with most of the population concentrated in the Twin Cities metro area. There are other smaller urban centers in the state, including Rochester in southeastern Minnesota, and Duluth in northeastern Minnesota. Aside from these urban centers, much of the state is rural. Access to transportation varies widely for Minnesota residents. While light rail and other public transportation options are expanding in the Twin Cities metro area, access to these options varies by neighborhood and population. In addition, access to transportation is still challenging in rural areas, where public transportation may be very limited or not available. Minnesota s extreme winter weather can also pose transportation challenges throughout the state during winter months. 15 P age

16 Figure 1.2. Susan G. Komen Minnesota Service Area 16 P age

17 Purpose of the Community Profile Report The Community Profile will help Susan G. Komen Minnesota align its community outreach, grantmaking and public policy activities towards the same Mission goal. The Purpose of the Community Profile Report is to: Align the Affiliate s strategic and operational plans Drive inclusion efforts in the community Drive public policy efforts Establish focused granting priorities Establish focused education needs Establish directions for marketing and outreach Strengthen sponsorship and partnership efforts The Affiliate expects to disseminate the Community Profile Report widely. The report will be shared with legislators and representatives from health care systems, including the Minnesota Department of Health, American Cancer Society, health plans, health care providers, and others. The report will also be available to the general public in a variety of formats, including the Affiliate s website and social media. 17 P age

18 Quantitative Data: Measuring Breast Cancer Impact in Local Communities Introduction The purpose of the quantitative data for Susan G. Komen Minnesota is to combine evidence from many credible sources and use the data to identify the highest priority areas for evidencebased breast cancer programs. The data provided in the report are used to identify priorities within the Affiliate s service area based on estimates of how long it would take an area to achieve Healthy People 2020 objectives for breast cancer late-stage diagnosis and death rates ( Quantitative Data Exploration Susan G. Komen Minnesota s service area includes all of Minnesota s 87 counties. Since many of these counties are rural, breast cancer death rates for about half (43) of the counties in the service area are suppressed at the county level, and trend data cannot be reported for 47 counties. In order to have complete data on the service area to examine the time needed to achieve Healthy People 2020 breast cancer goals for late-stage incidence and death rates, the Affiliate partnered with the Minnesota Department of Health and Wilder Research to obtain and analyze breast cancer death rate and late-stage incidence rate data from the Minnesota Cancer Surveillance System (MCSS) for the entire state of Minnesota. The following summarizes how these data were used to identify and select priority areas for the Minnesota Affiliate. Community Health Board Groupings Counties were first grouped by Community Health Board (CHB) areas. Community Health Boards provide public health infrastructure for all 87 Minnesota counties. Some Community Health Boards are single county entities, and others are groups of rural counties (Figure 2.1). The goal of examining breast cancer statistical data by CHB areas was to get a more complete picture of the quantitative data related to breast cancer by reducing the proportion of the Affiliate s service area for which data needed to be suppressed due to small numbers. All late-stage incidence and death rate data presented in this section are grouped by Community Health Boards. 18 P age

19 Figure 2.1. Map of Minnesota Community Health Boards 19 P age

20 Breast cancer statistics Overall rates and trends for late-stage incidence and deaths from breast cancer were calculated for each Community Health Board (CHB) area in Minnesota. These rates and trends were then used to calculate the time needed to achieve Healthy People 2020 goals for late-stage incidence and breast cancer death rates. Healthy People 2020 forecasts Healthy People 2020 (HP2020) is a major federal government initiative that provides specific health objectives for communities and for the country as a whole. Many national health organizations use HP2020 targets to monitor progress in reducing the burden of disease and improve the health of the nation. Likewise, Komen believes it is important to refer to HP2020 to see how areas across the country are progressing towards reducing the burden of breast cancer. HP2020 has several cancer-related objectives, including: Reducing women s death rate from breast cancer (Target: 20.6 per 100,000 women). Reducing the number of breast cancers that are found at a late-stage (Target: 41.0 cases per 100,000 women). To see how well CHB areas in the Affiliate service area are progressing toward these targets, the report uses the following information: CHB area breast cancer death rate for years 2006 through 2010 and late-stage diagnosis rate for years 2005 through 2009, the most recent available data. Estimates for the trend (annual percent change) in CHB area breast cancer death rates using data for years 1988 through 2010 and late-stage diagnoses using data for years 1995 through Annual percentage change for each CHB was calculated following the methods used in the Quantitative Data Report. Both the data and the HP2020 target are age-adjusted. These data are used to estimate how many years it will take for each CHB area to meet the HP2020 objectives. The target date for meeting the objectives is Since 2008 (the middle of the period) was used as a starting point for death rates, CHB areas have 12 years to meet the target. Similarly, since 2007 (the middle of the period) was used as a starting point for late-stage incidence, CHB areas have 13 years to meet this target. Death rate and late-stage diagnosis rate and trends are used to calculate whether an area will meet the HP2020 target, assuming that the trend continues. The calculation of predicted number of years to achieve the target followed the procedures used in the Quantitative Data Report. Late-stage incidence rates The late-stage incidence rate shows the frequency of late-stage (regional and distant) breast cancer diagnoses among women living in an area during a certain period of time. The female late-stage incidence rate is calculated as the annual number of females in an area who were diagnosed with a late-stage breast cancer divided by the total number of females living in that area, and expressed as an age-adjusted rate per 100,000 females. To show trends (changes over time) in late-stage incidence, data for the annual percent change in the late-stage incidence rate using a 15-year period ( ) were calculated for all 20 P age

21 CHB areas. The annual percent change is the average year-to-year change of the late-stage incidence rate. It may be either a positive or negative number. A negative value means that the rates are getting lower. A positive value means that the rates are getting higher. The Healthy People 2020 goal for late-stage incidence is 41.0 cases per 100,000 women. Table 2.1 shows the overall late-stage incidence rate for a five-year period ( ), the trend in annual percent change, and the predicted time needed to achieve the HP2020 goal for late-stage incidence for each CHB area. Table 2.1. Predicted number of years needed to achieve HP2020 target for age-adjusted female breast cancer late-stage incidence rates. Target is 41.0 cases per 100,000. County and CHB Groupings Base rate for years Trend in annual percent change ( ) Predicted number of years to achieve HP2020 Target Minnesota 38.4 N/A Currently meets target Aitkin-Itasca-Koochiching CHB Currently meets target Beltrami-Clearwater-Hubbard-Lake of the Woods-North Country CHB Big Stone-Chippewa-LQP-Swift-Yellow Medicine- Countryside CHB Currently meets target Currently meets target Brown-Nicollet CHB years or longer Carlton-Cook-Lake-St. Louis CHB Currently meets target Clay-Wilkin CHB SN SN SN Cottonwood-Jackson CHB Currently meets target Dodge-Steele CHB Currently meets target Douglas-Grant-Pope-Stevens-Traverse-Horizon CHB Currently meets target Faribault-Martin CHB years or longer Fillmore-Houston CHB years or longer Isanti-Mille Lacs CHB Currently meets target Kanabec-Pine CHB years or longer Kandiyohi-Renville CHB Currently meets target Kittson-Marshall-Pennington-Red Lake- Roseau CHB years or longer Le Sueur-Waseca years Lincoln-Lyon-Murray-Pipestone-Redwood-Rock- SWHHS CHB years or longer Meeker-McLeod-Sibley CHB year Morrison-Todd-Wadena CHB Currently meets target Mahnomen-Norman-Polk CHB Currently meets target Anoka County Currently meets target 21 P age

22 County and CHB Groupings Base rate for years Trend in annual percent change ( ) Becker County SN SN SN Predicted number of years to achieve HP2020 Target Benton County years or longer Blue Earth County Currently meets target Carver County Currently meets target Cass County Currently meets target Chisago County years or longer Crow Wing County Currently meets target Dakota County years or longer Freeborn County years or longer Goodhue County Currently meets target Hennepin County Currently meets target Mower County Currently meets target Nobles County Currently meets target Olmsted County Currently meets target Otter Tail County Currently meets target Ramsey County years or longer Rice County Currently meets target Scott County Currently meets target Sherburne County Currently meets target Stearns County years or longer Wabasha County Currently meets target Washington County years or longer Watonwan County Currently meets target Winona County Currently meets target Wright County Currently meets target Note: 2008 is the earliest *year* that a county can meet the target. SN = data suppressed due to small number of cases (15 or fewer cases over 5 year period) Breast cancer late-stage incidence summary Minnesota currently meets the HP2020 goal for late-stage incidence, with 38.4 late-stage diagnoses per 100,000 women. Thirteen CHB areas, including six multi-county and seven single-county CHB areas, are estimated to take 14 or more years to reach the HP2020 goal of 41.0 cases per 100,000 women. These 13 CHB areas are: Brown-Nicollet Community Health Board Faribault-Martin Community Health Board Fillmore-Houston Community Health Board Kanabec-Pine Community Health Board Kittson-Marshall-Pennington-Red Lake-Roseau (Quin County) Community Health Board Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board 22 P age

23 Benton County Chisago County Dakota County Freeborn County Ramsey County Stearns County Washington County Among these 13 CHB areas, 10 have a positive annual percent change, which means that the rates are getting higher. Death rates Death rates show the frequency of deaths from breast cancer among women living in an area during a certain period of time. The death rate is calculated as the annual number of females in an area who died of breast cancer divided by the total number of females living in that area, and expressed as an ageadjusted rate per 100,000 females. To show trends (changes over time) in death rates, data for the annual percent change in the death rates over a 23-year period ( ) were calculated for all Community Health Board (CHB) areas. The annual percent change is the average year-to-year change of the latestage incidence rate. It may be either a positive or negative number. A negative value means that the rates are getting lower. A positive value means that the rates are getting higher. The Healthy People 2020 goal for the death rate is 20.6 cases per 100,000 women. Table 2.2 shows the overall death rate for a five-year period ( ), the trend in annual percent change, and the predicted time needed to achieve the HP2020 goal for the death rate for each CHB area. Table 2.2. Predicted number of years needed to achieve HP2020 target for age0adjusted female breast cancer death rate. Target is 20.6 cases per 100,000 County and CHB Groupings Base rate for years Trend in annual percent change ( ) Minnesota year Aitkin-Itasca-Koochiching CHB year Predicted number of years to achieve HP2020 Target Beltrami-Clearwater-Hubbard-Lake of the Wood- North Country CHB Currently meets target Big Stone-Chippewa-LacquiParle-Swift-Yellow Medicine-Countryside CHB Currently meets target Brown-Nicollet CHB Currently meets target Carlton-Cook-Lake-St. Louis CHB year Clay-Wilkin CHB Currently meets target 23 P age

24 County and CHB Groupings Base rate for years Trend in annual percent change ( ) Predicted number of years to achieve HP2020 Target Cottonwood-Jackson-Des Moines Valley CHB Currently meets target Dodge-Steele CHB Currently meets target Douglas-Grant-Pope-Stevens-Traverse-Horizon CHB years Faribault-Martin CHB years or longer Fillmore-Houston CHB years Isanti-Mille Lacs CHB year Kanabec-Pine CHB years or longer Kandiyohi-Renville CHB years Kittson-Marshall-Pennington-Red Lake-Roseau CHB Currently meets target Le Sueur-Waseca CHB Currently meets target Lincoln-Lyon-Murray-Pipestone-Redwood-Rock- SWHHS-CHB years Meeker-McLeod-Sibley CHB years Morrison-Todd-Wadena CHB years Polk-Norman-Mahnomen CHB year Anoka County Currently meets target Becker County Currently meets target Benton County years Blue Earth County Currently meets target Carver County years or longer Cass County Currently meets target Chisago County Currently meets target Crow Wing County Currently meets target Dakota County Currently meets target Freeborn County years or longer Goodhue County Currently meets target Hennepin County years Mower County years Nobles County SN SN SN Olmsted County Currently meets target Otter Tail County Currently meets target Ramsey County Currently meets target Rice County years Scott County years or longer Sherburne County years 24 P age

25 County and CHB Groupings Base rate for years Trend in annual percent change ( ) Predicted number of years to achieve HP2020 Target Stearns County Currently meets target Wabasha County SN SN SN Washington County years Watonwan County SN SN SN Winona County Currently meets target Wright County Currently meets target Note: 2009 is the earliest *year* that a county can meet the target. SN = data suppressed due to small number of cases (15 or fewer cases over 5 year period) Breast cancer death rate summary Minnesota s current breast cancer death rate is 20.8 deaths per 100,000 women. Using the current death rate and annual percent change (-2.5%), the Affiliate can estimate that it will take Minnesota one year to achieve the Healthy People 2020 goal for the breast cancer death rate. Five CHB areas, including two multi-county and three single-county CHB areas, are estimated to take 13 or more years to reach the HP2020 goal of 20.6 deaths per 100,000 women. These CHB areas are: Faribault-Martin Community Health Board Kanabec-Pine Community Health Board Carver County Freeborn County Scott County Four CHB areas are estimated to take eight or nine years to reach the HP2020 goal for deaths from breast cancer. These areas are: Fillmore-Houston Community Health Board Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board Sherburne County Washington County Mammography Screening Getting regular screening mammograms (and treatment if diagnosed) lowers the risk of dying from breast cancer. Screening mammography can find breast cancer early, when the chances of survival are highest. Table 2.3 shows some screening recommendations among major organizations for women at average risk. 25 P age

26 Table 2.3. Breast cancer screening recommendations for women at average risk* American Cancer Society National Comprehensive Cancer Network US Preventive Services Task Force Informed decision-making with a health care provider at age 40 Mammography every year starting at age 45 Mammography every other year beginning at age 55 *As of October 2015 Mammography every year starting at age 40 Informed decision-making with a health care provider ages Mammography every 2 years ages Because having regular mammograms lowers the chances of dying from breast cancer, it s important to know whether women are having mammograms when they should. This information can be used to identify groups of women who should be screened who need help in meeting the current recommendations for screening mammography. The Centers for Disease Control and Prevention s (CDC) Behavioral Risk Factors Surveillance System (BRFSS) collected the data on mammograms that are used in this report. The data come from interviews with women age 50 to 74 from across the United States. During the interviews, each woman was asked how long it has been since she has had a mammogram. The proportions in Table 2.3 are based on the number of women age 50 to 74 who reported in 2012 having had a mammogram in the last two years. The data have been weighted to account for differences between the women who were interviewed and all the women in the area. For example, if 20.0 percent of the women interviewed are Hispanic/Latina, but only 10.0 percent of the total women in the area are Hispanic/Latina, weighting is used to account for this difference. The report uses the mammography screening proportion to show whether the women in an area are getting screening mammograms when they should. Mammography screening proportion is calculated from two pieces of information: The number of women living in an area whom the BRFSS determines should have mammograms (i.e. women age 50 to 74). The number of these women who actually had a mammogram during the past two years. The number of women who had a mammogram is divided by the number who should have had one. For example, if there are 500 women in an area who should have had mammograms and 250 of those women actually had a mammogram in the past two years, the mammography screening proportion is 50.0 percent. Because the screening proportions come from samples of women in an area and are not exact, Table 2.4 includes confidence intervals. A confidence interval is a range of values that gives an idea of how uncertain a value may be. It s shown as two numbers a lower value and a higher 26 P age

27 one. It is very unlikely that the true rate is less than the lower value or more than the higher value. For example, if screening proportion was reported as 50.0 percent, with a confidence interval of 35.0 to 65.0 percent, the real rate might not be exactly 50.0 percent, but it s very unlikely that it s less than 35.0 or more than 65.0 percent. In general, screening proportions at the county level have fairly wide confidence intervals. The confidence interval should always be considered before concluding that the screening proportion in one county is higher or lower than that in another county. Table 2.4. Proportion of women ages with screening mammography in the last two years, self-report Population Group # of Women Interviewed (Sample Size) # w/ Self- Reported Mammogram Proportion Screened (Weighted Average) Confidence Interval of Proportion Screened US 174, , % 77.2%-77.7% Komen Minnesota Service Area (State of Minnesota) 4,240 3, % 80.0%-82.9% White 3,991 3, % 80.3%-83.2% Black/African-American % 71.3%-90.8% AIAN % 64.1%-94.9% API % 34.3%-82.6% Hispanic/ Latina % 58.3%-93.2% Non-Hispanic/ Latina 4,189 3, % 80.1%-83.0% Aitkin County - MN % 62.4%-98.6% Anoka County - MN % 76.6%-89.9% Becker County - MN % 63.1%-92.6% Beltrami County - MN % 75.9%-96.5% Benton County - MN % 64.6%-98.1% Big Stone County - MN SN SN SN SN Blue Earth County - MN % 68.7%-94.2% Brown County - MN % 65.5%-96.1% Carlton County - MN % 46.3%-87.3% Carver County - MN % 71.7%-97.7% Cass County - MN % 75.3%-97.6% Chippewa County - MN SN SN SN SN Chisago County - MN % 69.1%-98.7% Clay County - MN % 63.5%-96.1% 27 P age

28 Population Group # of Women Interviewed (Sample Size) # w/ Self- Reported Mammogram Proportion Screened (Weighted Average) Confidence Interval of Proportion Screened Clearwater County - MN SN SN SN SN Cook County - MN SN SN SN SN Cottonwood County - MN SN SN SN SN Crow Wing County - MN % 58.8%-90.4% Dakota County - MN % 76.0%-88.2% Dodge County - MN SN SN SN SN Douglas County - MN % 75.3%-99.1% Faribault County - MN % 40.5%-93.3% Fillmore County - MN % 72.8%-99.4% Freeborn County - MN % 55.5%-93.3% Goodhue County - MN % 57.0%-87.3% Grant County - MN SN SN SN SN Hennepin County - MN 1, % 82.7%-88.0% Houston County - MN % 49.4%-90.8% Hubbard County - MN % 56.9%-95.1% Isanti County - MN % 47.0%-90.6% Itasca County - MN % 69.6%-94.2% Jackson County - MN SN SN SN SN Kanabec County - MN SN SN SN SN Kandiyohi County - MN % 50.3%-90.0% Kittson County - MN SN SN SN SN Koochiching County - MN % 31.8%-76.8% Lac qui Parle County - MN SN SN SN SN Lake County - MN SN SN SN SN Lake of the Woods County - MN SN SN SN SN Le Sueur County - MN % 48.2%-92.1% Lincoln County - MN SN SN SN SN Lyon County - MN % 42.5%-91.0% Mahnomen County - MN SN SN SN SN Marshall County - MN SN SN SN SN Martin County - MN % 45.1%-91.2% McLeod County - MN % 54.8%-92.3% 28 P age

29 Population Group # of Women Interviewed (Sample Size) # w/ Self- Reported Mammogram Proportion Screened (Weighted Average) Confidence Interval of Proportion Screened Meeker County - MN % 41.5%-93.5% Mille Lacs County - MN % 64.6%-97.3% Morrison County - MN % 52.3%-92.0% Mower County - MN % 76.9%-98.9% Murray County - MN SN SN SN SN Nicollet County - MN % 46.1%-94.8% Nobles County - MN % 50.2%-95.2% Norman County - MN SN SN SN SN Olmsted County - MN % 62.5%-86.0% Otter Tail County - MN % 71.0%-92.8% Pennington County - MN % 57.8%-97.3% Pine County - MN % 54.8%-92.7% Pipestone County - MN SN SN SN SN Polk County - MN % 59.5%-91.1% Pope County - MN SN SN SN SN Ramsey County - MN % 75.2%-82.8% Red Lake County - MN SN SN SN SN Redwood County - MN % 57.0%-91.0% Renville County - MN % 63.0%-99.2% Rice County - MN % 50.9%-81.7% Rock County - MN SN SN SN SN Roseau County - MN % 36.0%-91.5% St. Louis County - MN % 77.1%-90.9% Scott County - MN % 63.5%-90.5% Sherburne County - MN % 44.0%-78.0% Sibley County - MN SN SN SN SN Stearns County - MN % 66.0%-87.1% Steele County - MN % 59.0%-95.1% Stevens County - MN SN SN SN SN Swift County - MN SN SN SN SN Todd County - MN % 40.6%-84.7% Traverse County - MN SN SN SN SN 29 P age

30 Population Group # of Women Interviewed (Sample Size) # w/ Self- Reported Mammogram Proportion Screened (Weighted Average) Confidence Interval of Proportion Screened Wabasha County - MN % 36.9%-87.2% Wadena County - MN % 63.2%-100% Waseca County - MN % 67.0%-98.0% Washington County - MN % 67.5%-84.4% Watonwan County - MN SN SN SN SN Wilkin County - MN SN SN SN SN Winona County - MN % 52.8%-88.6% Wright County - MN % 73.6%-94.3% Yellow Medicine County - MN SN SN SN SN SN data suppressed due to small numbers (fewer than 10 samples). Data are for Source: CDC Behavioral Risk Factor Surveillance System (BRFSS). Breast cancer screening proportions summary The breast cancer screening proportion in the Komen Minnesota service area was significantly higher than that observed in the US as a whole. For the United States, breast cancer screening proportions among Blacks/African-Americans are similar to those among Whites overall. APIs have somewhat lower screening proportions than Whites and Blacks/African-Americans. Although data are limited, screening proportions among AIANs are similar to those among Whites. Screening proportions among Hispanics/Latinas are similar to those among Non-Hispanic Whites and Blacks/African- Americans. For the Affiliate service area as a whole, the screening proportion was not significantly different among Blacks/African-Americans than Whites, not significantly different among APIs than Whites, and not significantly different among AIANs than Whites. The screening proportion among Hispanics/Latinas was not significantly different than among Non- Hispanics/Latinas. The following counties had a screening proportion significantly lower than the Affiliate service area as a whole: Koochiching County Sherburne County The remaining counties had screening proportions that were not significantly different than the Affiliate service area as a whole. Population Characteristics Basic information about the women in each area (demographic measures) and about factors like education, income, and unemployment (socioeconomic measures) in the areas where they live is provided in Tables 2.5 and 2.6. Demographic and socioeconomic data can be used to identify which groups of women are most in need of help and to figure out the best ways to help them. 30 P age

31 It is important to note that the report uses the race and ethnicity categories used by the US Census Bureau, and that race and ethnicity are separate and independent categories. This means that everyone is classified as both a member of one of the four race groups as well as either Hispanic/Latina or Non-Hispanic/Latina. The demographic and socioeconomic data in this report are the most recent data available for US counties. All the data are shown as percentages. However, the percentages weren t all calculated in the same way. The race, ethnicity, and age data are based on the total female population in the area (e.g. the percent of females over the age of 40). The socioeconomic data are based on all the people in the area, not just women. Income, education and unemployment data don t include children. They re based on people age 15 and older for income and unemployment and age 25 and older for education. The data on the use of English, called linguistic isolation, are based on the total number of households in the area. The Census Bureau defines a linguistically isolated household as one in which all the adults have difficulty with English. 31 P age

32 Table 2.5. Population characteristics demographics Population Group White Black /African- American AIAN API Non- Hispanic /Latina Hispanic /Latina Female Age 40 Plus Female Age 50 Plus Female Age 65 Plus US 78.8 % 14.1 % 1.4 % 5.8 % 83.8 % 16.2 % 48.3 % 34.5 % 14.8 % Komen Minnesota Service Area (State of Minnesota) 88.1 % 5.8 % 1.5 % 4.6 % 95.4 % 4.6 % 48.4 % 34.6 % 14.6 % Aitkin County - MN 96.2 % 0.7 % 2.8 % 0.3 % 98.9 % 1.1 % 66.3 % 54.7 % 28.2 % Anoka County - MN 89.6 % 4.9 % 0.9 % 4.5 % 96.4 % 3.6 % 47.9 % 31.8 % 11.2 % Becker County - MN 89.8 % 0.7 % 8.9 % 0.6 % 98.7 % 1.3 % 53.5 % 41.6 % 18.8 % Beltrami County - MN 76.5 % 1.0 % 21.5 % 1.1 % 98.3 % 1.7 % 45.1 % 33.8 % 14.4 % Benton County - MN 95.9 % 2.2 % 0.7 % 1.2 % 98.2 % 1.8 % 44.1 % 31.1 % 13.7 % Big Stone County - MN 99.0 % 0.3 % 0.5 % 0.2 % 99.1 % 0.9 % 61.0 % 49.8 % 27.9 % Blue Earth County - MN 94.5 % 2.9 % 0.4 % 2.1 % 97.6 % 2.4 % 40.7 % 30.5 % 13.8 % Brown County - MN 98.6 % 0.4 % 0.1 % 0.8 % 96.9 % 3.1 % 56.0 % 43.4 % 21.9 % Carlton County - MN 92.3 % 0.6 % 6.4 % 0.7 % 98.9 % 1.1 % 52.8 % 38.9 % 17.4 % Carver County - MN 94.7 % 1.6 % 0.4 % 3.3 % 96.1 % 3.9 % 46.1 % 28.3 % 9.7 % Cass County - MN 86.4 % 0.6 % 12.5 % 0.5 % 98.5 % 1.5 % 59.1 % 47.0 % 22.2 % Chippewa County - MN 96.5 % 0.8 % 1.3 % 1.4 % 95.0 % 5.0 % 55.4 % 42.8 % 21.8 % Chisago County - MN 97.6 % 0.6 % 0.5 % 1.2 % 98.5 % 1.5 % 50.8 % 33.9 % 13.5 % Clay County - MN 95.2 % 1.5 % 1.6 % 1.7 % 96.5 % 3.5 % 41.3 % 30.1 % 13.3 % Clearwater County - MN 88.4 % 0.8 % 10.4 % 0.3 % 98.5 % 1.5 % 53.7 % 42.5 % 20.2 % Cook County - MN 88.9 % 0.9 % 9.3 % 0.8 % 98.6 % 1.4 % 64.4 % 51.1 % 22.1 % Cottonwood County - MN 95.5 % 1.2 % 0.3 % 3.0 % 93.6 % 6.4 % 56.4 % 44.4 % 23.9 % Crow Wing County - MN 97.6 % 0.7 % 1.1 % 0.6 % 98.8 % 1.2 % 54.8 % 42.3 % 20.2 % Dakota County - MN 88.7 % 5.4 % 0.6 % 5.2 % 94.2 % 5.8 % 47.7 % 32.1 % 11.6 % Dodge County - MN 98.0 % 0.8 % 0.5 % 0.8 % 95.4 % 4.6 % 46.8 % 32.2 % 13.9 % Douglas County - MN 98.4 % 0.6 % 0.4 % 0.6 % 99.0 % 1.0 % 55.7 % 43.6 % 21.9 % Faribault County - MN 98.6 % 0.4 % 0.6 % 0.4 % 94.6 % 5.4 % 58.5 % 46.4 % 24.9 % Fillmore County - MN 98.9 % 0.4 % 0.2 % 0.5 % 99.1 % 0.9 % 55.2 % 42.9 % 21.7 % Freeborn County - MN 97.6 % 1.0 % 0.3 % 1.1 % 91.9 % 8.1 % 56.9 % 44.2 % 22.8 % Goodhue County - MN 96.7 % 1.2 % 1.3 % 0.8 % 97.3 % 2.7 % 54.5 % 40.8 % 18.9 % Grant County - MN 98.3 % 0.8 % 0.3 % 0.6 % 98.3 % 1.7 % 57.5 % 45.4 % 23.1 % Hennepin County - MN 78.7 % 13.0 % 1.4 % 6.9 % 93.7 % 6.3 % 46.4 % 32.8 % 13.1 % Houston County - MN 98.1 % 0.9 % 0.2 % 0.7 % 99.2 % 0.8 % 56.8 % 43.1 % 19.8 % Hubbard County - MN 95.4 % 0.7 % 3.4 % 0.5 % 98.4 % 1.6 % 59.3 % 46.4 % 22.1 % Isanti County - MN 97.2 % 1.0 % 0.6 % 1.2 % 98.3 % 1.7 % 48.5 % 33.7 % 14.4 % Itasca County - MN 94.9 % 0.5 % 4.0 % 0.6 % 98.9 % 1.1 % 57.8 % 45.2 % 20.5 % Jackson County - MN 97.2 % 0.6 % 0.5 % 1.7 % 97.3 % 2.7 % 56.8 % 44.5 % 22.3 % 32 P age

33 Population Group White Black /African- American AIAN API Non- Hispanic /Latina Hispanic /Latina Female Age 40 Plus Female Age 50 Plus Female Age 65 Plus Kanabec County - MN 97.9 % 0.7 % 0.8 % 0.6 % 98.4 % 1.6 % 53.8 % 40.4 % 18.1 % Kandiyohi County - MN 96.3 % 2.5 % 0.5 % 0.7 % 89.3 % 10.7 % 52.0 % 40.0 % 18.4 % Kittson County - MN 98.8 % 0.4 % 0.4 % 0.5 % 98.4 % 1.6 % 61.8 % 49.4 % 25.3 % Koochiching County - MN 95.3 % 1.2 % 2.8 % 0.7 % 98.8 % 1.2 % 59.0 % 45.8 % 21.3 % Lac qui Parle County - MN 98.6 % 0.5 % 0.3 % 0.5 % 98.6 % 1.4 % 62.1 % 50.6 % 26.1 % Lake County - MN 98.3 % 0.6 % 0.7 % 0.4 % 99.2 % 0.8 % 60.6 % 48.6 % 23.7 % Lake of the Woods County - MN 97.0 % 1.0 % 0.9 % 1.1 % 98.7 % 1.3 % 62.2 % 49.7 % 22.0 % Le Sueur County - MN 98.1 % 0.7 % 0.4 % 0.8 % 94.8 % 5.2 % 50.9 % 36.3 % 15.7 % Lincoln County - MN 98.9 % 0.4 % 0.3 % 0.3 % 98.8 % 1.2 % 58.5 % 48.4 % 27.7 % Lyon County - MN 94.1 % 2.4 % 0.6 % 2.8 % 94.3 % 5.7 % 45.5 % 33.9 % 15.8 % Mahnomen County - MN 54.0 % 1.2 % 44.7 % 0.1 % 97.9 % 2.1 % 47.4 % 36.9 % 17.0 % Marshall County - MN 98.1 % 0.7 % 0.8 % 0.4 % 96.3 % 3.7 % 55.5 % 42.7 % 21.5 % Martin County - MN 98.2 % 0.6 % 0.4 % 0.8 % 96.7 % 3.3 % 57.7 % 45.9 % 23.5 % McLeod County - MN 98.0 % 0.7 % 0.3 % 1.0 % 95.0 % 5.0 % 51.5 % 37.5 % 17.9 % Meeker County - MN 98.7 % 0.5 % 0.2 % 0.5 % 96.8 % 3.2 % 52.9 % 39.7 % 18.5 % Mille Lacs County - MN 92.1 % 0.7 % 6.7 % 0.6 % 98.6 % 1.4 % 51.2 % 37.3 % 18.2 % Morrison County - MN 98.5 % 0.7 % 0.4 % 0.5 % 98.8 % 1.2 % 52.6 % 39.4 % 18.4 % Mower County - MN 94.9 % 2.6 % 0.4 % 2.1 % 89.7 % 10.3 % 50.7 % 38.5 % 19.6 % Murray County - MN 98.0 % 0.6 % 0.3 % 1.1 % 97.1 % 2.9 % 58.7 % 47.3 % 24.4 % Nicollet County - MN 95.6 % 2.4 % 0.4 % 1.7 % 96.4 % 3.6 % 44.4 % 32.8 % 13.7 % Nobles County - MN 89.7 % 3.6 % 1.0 % 5.8 % 78.4 % 21.6 % 48.9 % 37.3 % 18.4 % Norman County - MN 96.1 % 0.9 % 2.4 % 0.6 % 95.6 % 4.4 % 57.3 % 45.1 % 23.8 % Olmsted County - MN 88.5 % 5.1 % 0.3 % 6.0 % 96.1 % 3.9 % 47.2 % 34.0 % 14.3 % Otter Tail County - MN 97.6 % 1.0 % 0.7 % 0.7 % 97.4 % 2.6 % 59.2 % 46.7 % 23.3 % Pennington County - MN 95.3 % 2.0 % 1.8 % 0.9 % 97.2 % 2.8 % 50.2 % 38.8 % 18.5 % Pine County - MN 95.3 % 0.9 % 3.2 % 0.5 % 98.5 % 1.5 % 55.0 % 41.0 % 18.9 % Pipestone County - MN 95.8 % 1.5 % 1.7 % 1.0 % 96.3 % 3.7 % 55.0 % 42.4 % 23.2 % Polk County - MN 96.2 % 1.1 % 1.8 % 1.0 % 94.6 % 5.4 % 51.7 % 39.2 % 19.1 % Pope County - MN 98.4 % 0.8 % 0.3 % 0.5 % 99.0 % 1.0 % 58.8 % 47.1 % 23.9 % Ramsey County - MN 74.3 % 12.2 % 1.3 % 12.2 % 93.2 % 6.8 % 45.4 % 33.2 % 13.9 % Red Lake County - MN 96.7 % 0.9 % 2.0 % 0.4 % 97.1 % 2.9 % 52.9 % 40.8 % 19.7 % Redwood County - MN 90.4 % 1.0 % 5.3 % 3.3 % 98.1 % 1.9 % 55.0 % 42.6 % 22.1 % Renville County - MN 97.9 % 0.5 % 0.8 % 0.7 % 93.5 % 6.5 % 56.4 % 43.4 % 22.0 % Rice County - MN 94.6 % 2.5 % 0.5 % 2.5 % 92.7 % 7.3 % 46.0 % 33.1 % 14.4 % 33 P age

34 Population Group White Black /African- American AIAN API Non- Hispanic /Latina Hispanic /Latina Female Age 40 Plus Female Age 50 Plus Female Age 65 Plus Rock County - MN 97.9 % 0.4 % 0.7 % 97.5 % 2.5 % 52.7 % 41.0 % 20.9 % Roseau County - MN 95.1 % 0.7 % 1.6 % 2.6 % 99.2 % 0.8 % 51.9 % 37.0 % 16.1 % St. Louis County - MN 94.5 % 1.6 % 2.6 % 1.3 % 98.8 % 1.2 % 52.6 % 40.6 % 18.1 % Scott County - MN 89.1 % 3.2 % 1.1 % 6.6 % 95.6 % 4.4 % 42.8 % 25.4 % 8.8 % Sherburne County - MN 96.2 % 1.6 % 0.5 % 1.7 % 97.9 % 2.1 % 42.7 % 26.7 % 9.6 % Sibley County - MN 98.0 % 0.8 % 0.4 % 0.9 % 92.7 % 7.3 % 52.1 % 38.2 % 18.6 % Stearns County - MN 93.9 % 3.4 % 0.4 % 2.4 % 97.2 % 2.8 % 43.9 % 31.5 % 13.7 % Steele County - MN 95.6 % 3.0 % 0.4 % 1.0 % 93.6 % 6.4 % 49.6 % 35.8 % 16.5 % Stevens County - MN 94.2 % 1.9 % 1.8 % 2.1 % 97.3 % 2.7 % 44.6 % 35.2 % 18.3 % Swift County - MN 97.9 % 1.0 % 0.7 % 0.4 % 96.3 % 3.7 % 56.9 % 44.7 % 23.3 % Todd County - MN 98.0 % 0.6 % 0.5 % 0.8 % 94.7 % 5.3 % 53.6 % 40.4 % 18.9 % Traverse County - MN 94.6 % 0.8 % 4.5 % 0.1 % 98.5 % 1.5 % 61.3 % 49.1 % 29.2 % Wabasha County - MN 98.4 % 0.7 % 0.3 % 0.6 % 97.6 % 2.4 % 55.0 % 40.8 % 18.7 % Wadena County - MN 97.7 % 1.2 % 0.6 % 0.5 % 98.5 % 1.5 % 55.5 % 44.1 % 24.0 % Waseca County - MN 93.7 % 3.7 % 1.5 % 1.0 % 93.9 % 6.1 % 49.6 % 35.8 % 16.1 % Washington County - MN 90.1 % 3.8 % 0.5 % 5.6 % 96.7 % 3.3 % 49.6 % 33.2 % 12.0 % Watonwan County - MN 96.7 % 1.1 % 1.1 % 1.1 % 79.1 % 20.9 % 52.8 % 40.7 % 20.8 % Wilkin County - MN 98.0 % 0.5 % 1.2 % 0.4 % 97.7 % 2.3 % 55.5 % 41.2 % 20.1 % Winona County - MN 95.8 % 1.3 % 0.4 % 2.5 % 97.7 % 2.3 % 44.3 % 33.5 % 15.1 % Wright County - MN 96.5 % 1.4 % 0.5 % 1.6 % 97.5 % 2.5 % 43.4 % 27.8 % 10.9 % Yellow Medicine County - MN 95.4 % 0.5 % 3.6 % 0.6 % 95.9 % 4.1 % 55.8 % 42.9 % 22.2 % Data are for Data are in the percentage of women in the population. Source: US Census Bureau Population Estimates 34 P age

35 Table 2.6. Population characteristics socioeconomics Population Group Less than HS Education Income Below 100% Poverty Income Below 250% Poverty (Age: 40-64) Unemployed Foreign Born Linguistically Isolated In Rural Areas In Medically Underserved Areas No Health Insurance (Age: 40-64) US 14.6 % 14.3 % 33.3 % 8.7 % 12.8 % 4.7 % 19.3 % 23.3 % 16.6 % Komen Minnesota Service Area (State of Minnesota) 8.4 % 11.0 % 24.4 % 6.9 % 7.1 % 2.3 % 26.7 % 14.9 % 8.6 % Aitkin County - MN 10.6 % 12.2 % 39.9 % 8.9 % 1.0 % 0.4 % % % 12.9 % Anoka County - MN 6.9 % 6.6 % 20.2 % 7.4 % 7.0 % 1.7 % 13.5 % 0.0 % 8.1 % Becker County - MN 10.0 % 11.5 % 32.1 % 5.2 % 1.3 % 0.2 % 75.5 % 26.2 % 11.5 % Beltrami County - MN 10.8 % 19.7 % 36.0 % 10.1 % 2.3 % 0.6 % 67.1 % % 13.5 % Benton County - MN 9.9 % 13.4 % 28.1 % 8.7 % 1.8 % 0.9 % 40.0 % 13.2 % 8.1 % Big Stone County - MN 10.6 % 11.2 % 33.9 % 3.3 % 0.8 % 0.5 % % 5.3 % 10.0 % Blue Earth County - MN 6.9 % 18.9 % 28.5 % 6.5 % 3.7 % 1.2 % 26.9 % 0.0 % 8.0 % Brown County - MN 10.6 % 10.0 % 26.4 % 5.0 % 1.7 % 1.0 % 34.9 % 0.0 % 7.5 % Carlton County - MN 8.9 % 11.2 % 29.3 % 7.5 % 1.6 % 0.4 % 55.2 % 4.6 % 10.2 % Carver County - MN 5.3 % 5.0 % 12.4 % 5.0 % 6.0 % 1.5 % 18.8 % 0.0 % 5.3 % Cass County - MN 9.9 % 15.1 % 38.0 % 9.2 % 1.1 % 0.2 % % % 12.6 % Chippewa County - MN 13.3 % 10.8 % 28.2 % 5.9 % 3.2 % 0.1 % 50.3 % 0.0 % 9.0 % Chisago County - MN 7.2 % 7.1 % 21.7 % 6.8 % 1.8 % 0.1 % 55.6 % 3.0 % 8.0 % Clay County - MN 7.0 % 13.0 % 27.3 % 5.9 % 2.9 % 0.8 % 27.9 % 55.6 % 7.7 % Clearwater County - MN 15.4 % 16.2 % 40.1 % 10.3 % 1.2 % 0.2 % % % 14.5 % Cook County - MN 6.7 % 9.1 % 31.8 % 6.4 % 2.5 % 0.0 % % 0.0 % 12.2 % Cottonwood County - MN Crow Wing County - MN 15.0 % 11.7 % 32.3 % 4.5 % 4.3 % 0.5 % 62.3 % 35.4 % 9.9 % 8.3 % 12.2 % 33.2 % 8.3 % 1.3 % 0.3 % 62.7 % 0.0 % 9.8 % Dakota County - MN 5.5 % 6.0 % 16.2 % 6.3 % 8.0 % 2.3 % 4.9 % 0.0 % 7.1 % Dodge County - MN 9.1 % 6.5 % 20.8 % 3.7 % 1.9 % 0.4 % 51.8 % 50.8 % 7.9 % Douglas County - MN 8.7 % 11.0 % 26.9 % 5.6 % 1.2 % 0.8 % 52.8 % 0.0 % 8.1 % Faribault County - MN 10.1 % 11.8 % 32.5 % 5.4 % 1.6 % 0.6 % 77.6 % 0.0 % 10.6 % Fillmore County - MN 12.7 % 12.6 % 30.0 % 5.8 % 1.1 % 1.0 % 93.3 % % 10.5 % Freeborn County - MN 12.7 % 11.2 % 32.0 % 5.0 % 3.2 % 1.3 % 42.8 % 0.0 % 9.6 % Goodhue County - MN 9.0 % 8.2 % 23.5 % 6.1 % 2.3 % 0.5 % 47.0 % 0.0 % 8.7 % Grant County - MN 11.3 % 12.4 % 32.3 % 6.5 % 1.2 % 0.6 % % % 10.2 % Hennepin County - MN 7.9 % 12.3 % 23.3 % 7.5 % 12.7 % 4.1 % 2.2 % 13.6 % 9.2 % Houston County - MN 9.4 % 9.0 % 26.2 % 5.3 % 1.1 % 0.3 % 57.4 % % 8.4 % 35 P age

36 Population Group Less than HS Education Income Below 100% Poverty Income Below 250% Poverty (Age: 40-64) Unemployed Foreign Born Linguistically Isolated In Rural Areas In Medically Underserved Areas No Health Insurance (Age: 40-64) Hubbard County - MN 8.5 % 12.0 % 35.6 % 6.1 % 1.3 % 0.4 % 83.4 % 16.5 % 11.8 % Isanti County - MN 8.4 % 8.2 % 26.3 % 8.9 % 1.3 % 0.1 % 62.3 % 0.0 % 8.6 % Itasca County - MN 7.5 % 11.4 % 32.8 % 10.1 % 1.0 % 0.3 % 79.4 % 23.1 % 10.7 % Jackson County - MN 9.4 % 11.2 % 28.9 % 3.2 % 2.3 % 0.4 % 69.1 % % 9.0 % Kanabec County - MN 13.2 % 12.0 % 35.6 % 11.0 % 0.9 % 0.6 % 77.4 % 0.0 % 10.8 % Kandiyohi County - MN 11.9 % 12.7 % 28.5 % 6.2 % 4.4 % 1.9 % 44.5 % 0.0 % 9.2 % Kittson County - MN 10.6 % 8.0 % 29.1 % 2.9 % 2.8 % 1.6 % % % 9.2 % Koochiching County - MN Lac qui Parle County - MN 10.6 % 12.6 % 32.0 % 7.3 % 5.0 % 0.3 % 47.0 % 84.6 % 11.4 % 11.5 % 9.1 % 29.6 % 3.6 % 1.0 % 0.1 % % 0.0 % 8.7 % Lake County - MN 7.3 % 11.2 % 29.2 % 6.0 % 1.0 % 0.1 % 67.0 % 0.0 % 9.2 % Lake of the Woods County - MN 11.2 % 15.9 % 36.9 % 4.4 % 2.0 % 0.0 % % 0.0 % 12.8 % Le Sueur County - MN 9.6 % 9.2 % 23.0 % 7.4 % 2.6 % 1.5 % 62.2 % 0.0 % 7.9 % Lincoln County - MN 9.5 % 9.4 % 31.7 % 4.2 % 1.4 % 0.2 % % % 10.7 % Lyon County - MN 10.1 % 13.1 % 27.2 % 3.9 % 5.2 % 2.9 % 47.9 % 7.5 % 8.7 % Mahnomen County - MN 16.5 % 26.4 % 45.6 % 13.4 % 0.7 % 0.5 % % % 14.2 % Marshall County - MN 13.8 % 8.8 % 27.0 % 5.5 % 1.7 % 0.3 % % % 9.7 % Martin County - MN 11.3 % 9.3 % 32.2 % 3.7 % 1.5 % 0.6 % 54.0 % 0.2 % 8.7 % McLeod County - MN 9.5 % 7.5 % 24.1 % 5.6 % 3.3 % 1.6 % 46.6 % 0.0 % 8.0 % Meeker County - MN 10.2 % 9.4 % 28.4 % 7.3 % 1.6 % 0.5 % 65.5 % 4.8 % 9.6 % Mille Lacs County - MN 12.3 % 13.4 % 34.7 % 10.2 % 1.2 % 0.2 % 70.8 % 6.8 % 11.1 % Morrison County - MN 12.7 % 13.1 % 33.6 % 8.3 % 1.0 % 0.6 % 72.8 % 7.4 % 11.1 % Mower County - MN 14.1 % 15.3 % 30.2 % 4.7 % 6.9 % 4.3 % 35.9 % 3.5 % 9.5 % Murray County - MN 10.5 % 9.9 % 27.9 % 3.6 % 1.5 % 0.3 % % % 9.6 % Nicollet County - MN 7.0 % 11.3 % 22.5 % 5.5 % 2.4 % 0.9 % 25.6 % 11.0 % 6.5 % Nobles County - MN 20.6 % 19.5 % 35.6 % 4.6 % 15.6 % 8.1 % 41.0 % 0.0 % 13.4 % Norman County - MN 12.6 % 12.7 % 32.5 % 5.1 % 1.6 % 0.5 % % % 10.8 % Olmsted County - MN 5.9 % 8.1 % 19.0 % 4.2 % 9.4 % 3.9 % 16.6 % 0.0 % 6.6 % Otter Tail County - MN 11.2 % 12.9 % 31.2 % 6.0 % 2.5 % 1.1 % 73.6 % 25.2 % 9.8 % Pennington County - MN 12.0 % 11.0 % 30.2 % 5.5 % 2.4 % 1.1 % 36.2 % 0.0 % 8.3 % Pine County - MN 13.2 % 15.0 % 37.1 % 9.5 % 1.7 % 0.8 % 89.3 % % 11.9 % Pipestone County - MN 14.3 % 11.3 % 33.7 % 5.1 % 2.9 % 0.6 % 57.3 % 8.5 % 12.5 % 36 P age

37 Population Group Less than HS Education Income Below 100% Poverty Income Below 250% Poverty (Age: 40-64) Unemployed Foreign Born Linguistically Isolated In Rural Areas In Medically Underserved Areas No Health Insurance (Age: 40-64) Polk County - MN 12.1 % 12.2 % 30.4 % 6.0 % 2.2 % 0.6 % 48.5 % % 8.3 % Pope County - MN 9.2 % 7.6 % 30.8 % 5.5 % 0.8 % 0.3 % % 0.0 % 8.9 % Ramsey County - MN 10.3 % 16.4 % 28.6 % 8.1 % 13.7 % 4.9 % 0.2 % 23.1 % 9.3 % Red Lake County - MN 13.0 % 10.4 % 33.4 % 5.1 % 1.5 % 1.3 % % % 12.4 % Redwood County - MN 12.9 % 10.5 % 30.0 % 4.7 % 2.1 % 0.6 % 69.1 % % 10.3 % Renville County - MN 12.1 % 10.8 % 29.1 % 6.1 % 2.9 % 0.7 % % 11.9 % 9.3 % Rice County - MN 10.2 % 10.8 % 23.7 % 6.5 % 6.7 % 2.3 % 25.9 % 5.0 % 8.9 % Rock County - MN 10.8 % 11.1 % 30.1 % 3.0 % 1.6 % 0.5 % 52.3 % 0.0 % 9.0 % Roseau County - MN 10.9 % 11.4 % 30.2 % 4.2 % 2.3 % 0.3 % 82.3 % % 9.2 % St. Louis County - MN 7.5 % 16.0 % 31.1 % 8.3 % 2.1 % 0.6 % 37.1 % 18.1 % 8.4 % Scott County - MN 5.8 % 5.0 % 15.2 % 5.9 % 8.2 % 1.7 % 17.2 % 0.0 % 6.9 % Sherburne County - MN 7.3 % 8.0 % 20.4 % 7.2 % 2.5 % 0.5 % 44.2 % 4.9 % 7.4 % Sibley County - MN 13.1 % 12.1 % 27.8 % 6.5 % 3.7 % 1.2 % % % 10.2 % Stearns County - MN 9.6 % 12.8 % 26.3 % 6.7 % 4.1 % 1.0 % 36.9 % 0.0 % 8.3 % Steele County - MN 9.2 % 8.8 % 23.9 % 5.9 % 3.3 % 1.6 % 30.6 % 0.0 % 8.0 % Stevens County - MN 8.6 % 14.3 % 26.0 % 7.1 % 3.7 % 1.3 % 47.3 % 0.0 % 8.3 % Swift County - MN 13.0 % 9.2 % 29.6 % 3.3 % 2.0 % 0.2 % 67.4 % % 9.7 % Todd County - MN 14.8 % 15.5 % 37.5 % 7.4 % 3.4 % 1.4 % 78.4 % 30.9 % 12.6 % Traverse County - MN 10.5 % 8.2 % 30.4 % 2.0 % 1.5 % 0.5 % % % 12.5 % Wabasha County - MN 8.8 % 7.6 % 25.2 % 4.6 % 1.5 % 0.3 % 64.5 % 5.9 % 8.4 % Wadena County - MN 11.7 % 18.0 % 43.2 % 6.3 % 1.1 % 0.7 % 67.0 % 25.0 % 12.2 % Waseca County - MN 8.5 % 8.4 % 27.5 % 5.1 % 2.7 % 0.7 % 50.2 % 13.4 % 8.5 % Washington County - MN 4.1 % 5.7 % 14.2 % 5.7 % 6.0 % 1.5 % 14.5 % 0.0 % 5.7 % Watonwan County - MN 18.4 % 10.4 % 31.4 % 5.7 % 10.3 % 3.8 % 59.1 % 36.5 % 12.8 % Wilkin County - MN 11.0 % 7.0 % 25.0 % 5.2 % 0.5 % 0.8 % 50.1 % % 8.5 % Winona County - MN 10.9 % 16.0 % 28.0 % 7.2 % 2.9 % 1.3 % 34.5 % 2.4 % 8.5 % Wright County - MN 6.7 % 5.6 % 21.1 % 6.3 % 2.5 % 0.7 % 32.5 % 3.3 % 8.3 % Yellow Medicine County - MN 10.5 % 13.8 % 28.4 % 4.2 % 1.7 % 0.4 % 80.8 % 0.4 % 9.1 % Data are in the percentage of people (men and women) in the population. Source of health insurance data: US Census Bureau Small Area Health Insurance Estimates (SAHIE) for Source of rural population data: US Census Bureau Census Source of medically underserved data: Health Resources and Services Administration (HRSA) for Source of other data: US Census Bureau American Community Survey (ACS) for P age

38 Population characteristics summary Proportionately, the Komen Minnesota service area has a substantially larger White female population than the US as a whole, a substantially smaller Black/African-American female population, a slightly smaller Asian and Pacific Islander (API) female population, a slightly larger American Indian and Alaska Native (AIAN) female population, and a substantially smaller Hispanic/Latina female population. The Affiliate s female population is about the same age as that of the US as a whole. The Affiliate s education level is substantially higher than and income level is slightly higher than those of the US as a whole. There is a slightly smaller percentage of people who are unemployed in the Affiliate service area. The Affiliate service area has a substantially smaller percentage of people who are foreign born and a slightly smaller percentage of people who are linguistically isolated. There is a substantially larger percentage of people living in rural areas, a substantially smaller percentage of people without health insurance, and a substantially smaller percentage of people living in medically underserved areas. The following counties have substantially larger Black/African-American female population percentages than that of the Affiliate service area as a whole: Hennepin County Ramsey County The following county has substantially larger API female population percentages than that of the Affiliate service area as a whole: Ramsey County The following counties have substantially larger AIAN female population percentages than that of the Affiliate service area as a whole: Becker County Beltrami County Carlton County Cass County Clearwater County Cook County Mahnomen County Mille Lacs County Redwood County The following counties have substantially larger Hispanic/Latina female population percentages than that of the Affiliate service area as a whole: Kandiyohi County Mower County Nobles County Watonwan County The following counties have substantially older female population percentages than that of the Affiliate service area as a whole: Aitkin County Big Stone County 38 Page

39 Brown County Cass County Chippewa County Clearwater County Cook County Cottonwood County Crow Wing County Douglas County Faribault County Fillmore County Freeborn County Grant County Houston County Hubbard County Itasca County Jackson County Kittson County Koochiching County Lac qui Parle County Lake County Lake of the Woods County Lincoln County Marshall County Martin County Murray County Norman County Otter Tail County Pipestone County Pope County Redwood County Renville County Swift County Traverse County Wadena County Wilkin County Yellow Medicine County The following counties have substantially lower education levels than that of the Affiliate service area as a whole: Clearwater County Cottonwood County Mahnomen County Marshall County Mower County Nobles County Pipestone County 39 Page

40 Todd County Watonwan County The following counties have substantially lower income levels than that of the Affiliate service area as a whole: Beltrami County Clearwater County Mahnomen County Nobles County Wadena County The following counties have substantially lower employment levels than that of the Affiliate service area as a whole: Beltrami County Clearwater County Itasca County Kanabec County Mahnomen County Mille Lacs County The county with substantial foreign born and linguistically isolated populations is: Nobles County The following counties have substantially larger percentage of adults without health insurance than does the Affiliate service area as a whole: Clearwater County Mahnomen County Priority Areas Healthy People 2020 forecasts Classification of priority areas are based on the time needed to achieve HP2020 targets in each Community Health Board (CHB) area. These time projections depend on both the starting point and the trends in death rates and late-stage incidence rates. Late-stage incidence rate likely reflects both the overall breast cancer incidence rate in the population and the mammography screening coverage. The breast cancer death rate likely reflects overall incidence, stage of diagnosis, and the access to care and the quality of care in the health care delivery area. There has not been any indication that either one of the two HP2020 targets is more important than the other. Therefore, the report considers them equally important. CHB areas are classified as follows (Table 2.7): CHB areas that are not likely to achieve either of the HP2020 targets are considered to have the highest needs. CHB areas that have already achieved both targets are considered to have the lowest needs. 40 P age

41 Other areas are classified based on the number of years needed to achieve the two targets. Table 2.7. Needs/priority classification based on the projected time to achieve HP2020 breast cancer targets Time to Achieve Late-stage Incidence Reduction Target 14 years or longer 8-13 years 0 7 years Currently meets target Unknown 13 years or longer Highest High Medium High Medium Highest Time to Achieve Death Rate Reduction Target 7 12 years High 0 6 years Medium High Medium High Medium Medium Medium Low Medium Low Low Medium High Medium Low Currently meets target Medium Medium Low Low Lowest Lowest Unknown Highest Medium High Medium Low Lowest Unknown If the time to achieve a target cannot be calculated for one of the HP2020 indicators, then the CHB area is classified based on the other indicator. If both indicators are missing, then the area is not classified. This does not mean that the area may not have high needs; it only means that sufficient data are not available to classify the area. Affiliate service area Healthy People 2020 forecasts and priority areas The results presented in Table 2.8 help identify which CHB areas have the greatest needs related to meeting the HP2020 breast cancer targets. For CHB areas in the 13 years or longer category for death rates, or in the 14 years or longer category for late-stage incidence, current trends would need to change to achieve the target. Some CHB areas may currently meet the target but their rates are increasing and they could fail to meet the target if the trend is not reversed. Trends can change for a number of reasons, including: Improved screening programs could lead to breast cancers being diagnosed earlier, resulting in a decrease in both late-stage incidence rates and death rates. Improved socioeconomic conditions, such as reductions in poverty and linguistic isolation could lead to more timely treatment of breast cancer, causing a decrease in death rates. The data in this table should be considered together with other information on factors that affect breast cancer death rates such as screening percentages and key breast cancer death determinants such as poverty and linguistic isolation. 41 P age

42 Table 2.8. Intervention priorities for Susan G. Komen Minnesota service area with predicted time to achieve HP2020 targets County and CHB Groupings Priority Predicted number of years to achieve HP2020 Mortality Target Predicted number of years to achieve HP2020 Late-Stage Incidence Target Faribault-Martin CHB Highest 13 years or longer 14 years or longer Kanabec-Pine CHB Highest 13 years or longer 14 years or longer Freeborn County Highest 13 years or longer 14 years or longer Fillmore-Houston CHB High 8 years 14 years or longer Lincoln-Lyon-Murray-Pipestone-Redwood- Rock-SWHHS-CHB High 8 years 14 years or longer Washington County High 8 years 14 years or longer Benton County Medium High 2 years 14 years or longer Brown-Nicollet CHB Medium Currently meets target 14 years or longer Kittson-Marshall-Pennington-Red Lake- Roseau CHB Medium Currently meets target 14 years or longer Carver County Medium 13 years or longer Currently meets target Chisago County Medium Currently meets target 14 years or longer Dakota County Medium Currently meets target 14 years or longer Ramsey County Medium Currently meets target 14 years or longer Scott County Medium 13 years or longer Currently meets target Stearns County Medium Currently meets target 14 years or longer Le Sueur-Waseca CHB Medium Low Currently meets target 12 years Meeker-McLeod-Sibley CHB Medium Low 2 years 1 year Sherburne County Medium Low 9 years Currently meets target Minnesota Low 1 year Currently meets target Aitkin-Itasca-Koochiching CHB Low 1 year Currently meets target Carlton-Cook-Lake-St. Louis CHB Low 1 year Currently meets target Douglas-Grant-Pope-Stevens-Traverse- Horizon CHB Low 2 years Currently meets target Isanti-Mille Lacs CHB Low 1 year Currently meets target Kandiyohi-Renville CHB Low 2 years Currently meets target Morrison-Todd-Wadena CHB Low 2 years Currently meets target Polk-Norman-Mahnomen CHB Low 1 year Currently meets target Hennepin County Low 5 years Currently meets target Mower County Low 2 years Currently meets target Rice County Low 3 years Currently meets target Beltrami-Clearwater-Hubbard-Lake of the Wood-North Country CHB Big Stone-Chippewa-LacquiParle-Swift- Yellow Medicine-Countryside CHB Lowest Currently meets target Currently meets target Lowest Currently meets target Currently meets target 42 P age

43 County and CHB Groupings Priority Predicted number of years to achieve HP2020 Mortality Target Clay-Wilkin CHB Lowest Currently meets target SN Cottonwood-Jackson-Des Moines Valley CHB Predicted number of years to achieve HP2020 Late-Stage Incidence Target Lowest Currently meets target Currently meets target Dodge-Steele CHB Lowest Currently meets target Currently meets target Anoka County Lowest Currently meets target Currently meets target Becker County Lowest Currently meets target SN Blue Earth County Lowest Currently meets target Currently meets target Cass County Lowest Currently meets target Currently meets target Crow Wing County Lowest Currently meets target Currently meets target Goodhue County Lowest Currently meets target Currently meets target Nobles County Lowest SN Currently meets target Olmsted County Lowest Currently meets target Currently meets target Otter Tail County Lowest Currently meets target Currently meets target Wabasha County Lowest SN Currently meets target Watonwan County Lowest SN Currently meets target Winona County Lowest Currently meets target Currently meets target Wright County Lowest Currently meets target Currently meets target HP2020 Conclusions Three CHB areas in Komen Minnesota s service area are classified as highest priority (Table 2.7). It is estimated that it would take 13 or more years to reach the HP2020 target for the death rate and 14 or more years to reach the target for the late-stage incidence rate in each of these areas. These three CHB areas are: Faribault-Martin Community Health Board Kanabec-Pine Community Health Board Freeborn County In addition, three CHB areas are classified as high priority. It is estimated that it would take 8 years to reach the HP2020 target for the death rate and 14 or more years to reach the target for the late-stage incidence rate in each of these areas. These three CHB areas are: Fillmore-Houston Community Health Board Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board Washington County Data Limitations The following data limitations need to be considered when utilizing the additional quantitative data in this report: The most recent data available were used but, for cancer incidence and mortality, these data are still several years behind. For some areas, data might not be available or might be of varying quality. 43 P age

44 Areas with small populations might not have enough breast cancer cases or breast cancer deaths each year to support the generation of reliable statistics. Data on cancer rates for specific racial and ethnic subgroups such as Somali or Hmong are not generally available. The various types of breast cancer data in this report are inter-dependent. There are many factors that impact breast cancer risk and survival for which quantitative data are not available. Some examples include family history, genetic markers like HER2 and BRCA, other medical conditions that can complicate treatment, and the level of family and community support available to the patient. The calculation of the years needed to meet the HP2020 objectives assume that the current trends will continue until However, the trends can change for a number of reasons. Not all breast cancer cases have a stage indication. Selection of Target Communities Susan G. Komen Minnesota has chosen five target communities within the service area. The Affiliate will focus strategic efforts on these target communities over the course of the next four years. When selecting target communities, the Affiliate reviewed Healthy People 2020, a major federal government initiative that provides specific health objectives for communities and the country as a whole. Specific to Komen Minnesota s work, goals around reducing women s death rate from breast cancer and reducing the number of breast cancers found at a late-stage were analyzed by Community Health Board area. Through this review, areas of priority were identified based on the time needed to meet Healthy People 2020 targets for breast cancer. Additional key indicators the Affiliate reviewed when selecting target counties included, but were not limited to: Incidence rates and trends Death rates and trends Late-stage rates and trends Screening percentages Percentage of residents living in a rural area Percentage of residents who are American Indian/Alaska Native Percentage of female residents who are over 40, over 50, and over 65 The selected target communities are: Faribault-Martin Community Health Board and Freeborn County area, which encompasses Faribault, Martin, and Freeborn Counties in Minnesota Kanabec-Pine Community Health Board area, which encompasses Kanabec and Pine Counties in Minnesota Fillmore-Houston Community Health Board area, which encompasses Fillmore and Houston Counties in Minnesota Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board area, which encompasses Lincoln, Lyon, Murray, Pipestone, Redwood, and Rock Counties in Minnesota Washington County, Minnesota 44 P age

45 Figure 2.2 shows the location of the selected target communities by Community Health Board area. Figure 2.2. Location of the five target communities in Minnesota by Community Health Boards 45 P age

46 Faribault-Martin-Freeborn Counties Faribault, Martin, and Freeborn counties are adjacent, and have been combined into one region for the purpose of this report and for the Affiliate s targeted efforts. The Faribault-Martin- Freeborn region is located in southern Minnesota and aligns with the Minnesota state border with Iowa. These counties have been chosen because the estimated time to achieve HP2020 targets for the death rate and late-stage incidence rate are 13 years or more and 14 years or more, respectively. This data places this region into the highest priority for intervention. All three counties in this region are considered rural, and have an older than average female population. Kanabec-Pine Community Health Board Area Kanabec and Pine counties are adjacent, and have been combined into one region for the purpose of this report and for the Affiliate s targeted efforts. The Kanabec-Pine region is located in east-central Minnesota and aligns with the Minnesota state border with Wisconsin. Kanabec and Pine counties share public health infrastructure and resources. This CHB has been chosen because the estimated time to achieve HP2020 targets for the death rate and late-stage incidence rate are 13 years or more and 14 years or more, respectively. This data places this region into the highest priority category. All counties in this CHB are considered rural. Residents of both Kanabec and Pine Counties are more likely to live below 250 percent of the federal poverty level and be unemployed, which could present difficulties in accessing breast health care. Fillmore-Houston Community Health Board Area Fillmore and Houston counties are adjacent, and have been combined into one region for the purpose of this report and for the Affiliate s targeted efforts. These counties share public health infrastructure and resources. The Fillmore-Houston CHB is located in the southeast corner of Minnesota and share borders with both Iowa and Wisconsin. This CHB area has been chosen because the estimated time to achieve HP2020 targets for the late-stage incidence rate is 14 years or more, and for the death rate, eight years. This data places this region into the high priority category. Both counties in this CHB area are considered rural, have an older than average female population, and are considered medically underserved areas. Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board Area Lincoln, Lyon, Murray, Pipestone, Redwood, and Rock counties are adjacent, and have been combined into one region for the purpose of this report and for the Affiliate s targeted efforts. These counties share public health infrastructure and resources. The Lincoln-Lyon-Murray- Pipestone-Redwood-Rock CHB area is located in southwest Minnesota and shares borders with both Iowa and South Dakota. 46 P age

47 These counties have been chosen because the estimated time to achieve HP2020 targets is eight years for the death rate and 14 or more years for the late-stage incidence rate. This data places this CHB area into the high priority category. All counties in this region are considered rural. Additionally, four of six counties also have an older than average female population, one county has lower than average education levels, and one has a higher than average percentage of residents who are American Indian. Washington County Washington County is located in east-central Minnesota and is adjacent to the Wisconsin border. This county is part of the Minneapolis-Saint Paul metropolitan area, and is considered mostly suburban. However, it should be noted that this county is geographically large, and parts of the county may be considered rural. This county was chosen because the estimated time to achieve the HP2020 targets is 8 years for the death rate and 14 or more years for the late-stage incidence rate. This places Washington County into the high priority category. Issues to be Explored Further by the Health Systems Analysis In order to understand the assets and gaps in services for women in the target communities of Minnesota, the Community Profile Team will approach the Health Systems Analysis through the lens of the continuum of care. The continuum of care reflects each point of the breast health system that a woman may encounter, whether she experiences breast cancer or not. It is critical to assess the resources and gaps that all women within a community may experience, regardless of diagnosis. The continuum will also be used to help define and understand existing and needed partnerships, advocacy efforts, and legislator support. 47 P age

48 Health Systems and Public Policy Analysis Health Systems Analysis Data Sources The Health System Analysis component of the Community Profile assessed the availability of services and resources in the identified target areas. Sites included in data collection were 1) sites where mammography services were available, identified through the US Food and Drug Administration Mammography Facility Database, and 2) sites identified as Sage (Minnesota s Breast and Cervical Cancer Control Program) providers. The Profile team developed a 25-item close-ended survey. Clinics and hospitals were given the option of completing the survey by telephone or electronically, using a web survey or fillable document. A total of 81 clinics and hospitals were identified within the target areas; 74 clinics and hospitals completed the survey over the phone or electronically. Partially completed surveys were collected from an additional two sites. Five clinics/hospitals were unable or unwilling to complete a survey despite numerous attempts to contact them. In addition to the telephone and electronic surveys, the Profile team also identified resources for cancer patients and their caregivers in the target areas using the American Cancer Society website. The website includes a public registry of available services and resources throughout Minnesota. While not specific to breast cancer, the site provides services that could be utilized by many breast cancer patients, including but not limited to: financial assistance, prosthetics, legal assistance, symptom management, support groups, and end of life care. Findings were examined geographically by target community. Health Systems Overview The Breast Cancer Continuum of Care (CoC) is a model that shows how a woman typically moves through the health care system for breast care (Figure 3.1). A woman would ideally move through the CoC quickly and seamlessly, receiving timely, quality care in order to have the best outcomes. Education can play an important role throughout the entire CoC. While a woman may enter the continuum at any point, ideally a woman would enter the CoC by getting screened for breast cancer with a clinical breast exam or a screening mammogram. If the screening test results are normal, she would loop back into follow-up care, where she would get another screening exam at the recommended interval. Education plays a role in both encouraging women to get screened and reinforcing the need to continue to get screened routinely thereafter. If a screening exam results in abnormal findings, diagnostic tests would be needed, possibly several, to determine if the abnormal finding is breast cancer. These tests might include a diagnostic mammogram, breast ultrasound or biopsy. If the tests are negative (or benign) and breast cancer is not found, she would go into the follow-up loop, and return for screening at the recommended interval. The recommended intervals may range from three to six months for some women to 12 months for most women. Education plays a role in communicating the importance of proactively getting test results, keeping follow-up appointments, and understanding what it all means. Education can empower a woman and help manage anxiety and fear. 48 P age

49 If breast cancer is diagnosed, the woman would proceed to treatment. Education can cover such topics as treatment options, how a pathology report determines the best options for treatment, understanding side effects and how to manage them, and helping to formulate questions a woman may have for her providers. For some breast cancer patients, treatment may last a few months and for others, it may last years. While the CoC model shows that follow-up and survivorship come after treatment ends, they may occur at the same time. Follow-up and survivorship may include things like navigating insurance issues, locating financial assistance, and symptom management, such as pain, fatigue, sexual issues, bone health, etc. Education may address topics such as making healthy lifestyle choices, long-term effects of treatment, managing side effects, the importance of followup appointments, and communication with their providers. Most women will return to screening at a recommended interval after treatment ends; for some, they will return to screening during treatment (such as those taking long-term hormone therapy). There are often delays in moving from one point of the continuum to another at the point of follow-up of abnormal screening exam results, starting treatment, and completing treatment that can all contribute to poorer outcomes. There are also many reasons why a woman does not enter or continue in the breast cancer CoC. These barriers can include things such as: lack of transportation; system issues, including long waits for appointments and inconvenient clinic hours; lack of insurance or financial issues; language barriers; fear; and lack of information - or the wrong information (myths and misconceptions). Education can address some of these barriers and help a woman progress through the CoC more quickly. Figure 3.1. Breast Cancer Continuum of Care (CoC) 49 P age

50 Target areas Minnesota is generally a resource-rich state, especially within the Twin Cities metro area. Minnesota is home to a number of dedicated breast health centers, and many hospitals, clinics, and providers throughout the state. While there are many providers within the state, access to these services is unequal. Generally, there are fewer providers outside of the seven-county metro area and Olmsted County, where the Mayo Clinic systems are located. It should be noted that Komen Minnesota found that several providers in the target areas provide women with breast self-exam training. Susan G. Komen supports a more comprehensive approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is normal for the individual, and making healthy lifestyle choices. These findings provide the Affiliate with an opportunity to partner with local health care providers in the target communities to provide Komen s breast self-awareness messaging through educational opportunities. Faribault-Martin-Freeborn Community Health Board Area Health system strengths and weaknesses A review of available services and programs within the Faribault-Martin-Freeborn region demonstrated that access to screening, diagnostic, and treatment services may be limited in this community (Figure 3.2). Some women may need to travel 30 or more miles to receive a mammogram. However, most providers accept all forms of insurance in this region, and many are Sage providers. In general, access to counseling and other support services was limited in this region. Providers The Community Profile Team gathered surveys from 15 providers in the Faribault-Martin- Freeborn region. Of the sites included in the provider surveys, 10 identified as Sage providers. Thirteen providers were nonprofit, and two were for-profit. Providers disclosed the payment and reimbursement sources accepted. Fourteen facilities reported that they accept Medicaid, private insurance, and Medicare. Services are available on a sliding fee scale at four clinics, and seven facilities reported charity care programs. The payment and reimbursement sources accepted at one facility are unknown. Screening, diagnosis and treatment Among the 15 providers who completed surveys in the Faribault-Martin-Freeborn region, 11 provided clinical breast exams. Four facilities provided some type of mammography services to residents in the counties. Four providers reported access to digital mammography, and two facilities offer same day mammography services. All providers in the target counties who do not provide mammography services onsite provide referrals for mammography services. While some providers reported that mammography was available within three miles, two reported that patients had to travel 30 or more miles for mammography services. Some patients may travel as far as 50 miles for those services. 50 P age

51 Five providers in the Faribault-Martin-Freeborn region provided ultrasound services. Four facilities provided surgical biopsy and computer aided detection (CAD). Fewer facilities provided other screening services, such as image guided breast biopsy (n=3), MRI (n=3), and sentinel node biopsy (n=1). As there were few hospitals within this region, it was expected that access to breast cancer treatment would likely be limited. Access to treatment services, such as radiation, oncology, chemotherapy, and surgery were available at two facilities in the Faribault-Martin-Freeborn region. Radiation oncology and reconstructive surgery were available at one facility in this region. Education Four providers in the Faribault-Martin-Freeborn region provided educational services. Four facilities reported that they provide breast self-exam training and breast health information. It should be noted that Susan G. Komen does not support the use of breast self-exam training. Rather, Susan G. Komen supports a more comprehensive approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is normal for the individual, and making healthy lifestyle choices. Three sites reported that they have a library of educational resources and provide community education. Counseling and other support services Among services assessed in the Faribault-Martin-Freeman region, access to counseling and other support services was most limited. Individual counseling or psychotherapy was available at four sites, and stress management and coping skills services were available at one site. In addition, patient advocates for financial assistance, and nurses or social workers who help patients navigate through screening, diagnosis, and treatment were each available at four sites. Three sites reported that they have hospice or palliative care services. Three sites in this region also offered nutritional services and physical therapy. One site reported that they use community health workers who support patients with screening, diagnosis, and treatment. Partnerships and opportunities for collaboration Susan G. Komen Minnesota currently partners with the Sage program, which serves 10 providers in the Faribault-Martin-Freeborn region. The Affiliate also funds several statewide programs which are available to residents in this area, including Cancer Legal Line. Cancer Legal Line s Breast Cancer Legal Project provides and coordinates pro bono legal services to low-income breast cancer patients and survivors in Minnesota. There may be opportunities for collaboration with Mayo Health System, which operates eight clinics in the Faribault-Martin- Freeborn region. The Affiliate may also consider ways to partner with providers of counseling and other support services in the region, as these services were somewhat limited. 51 P age

52 Figure 3.2. Breast Cancer Services Available in Faribault, Martin and Freeborn Counties 52 P age

53 Fillmore-Houston Community Health Board Area Health system strengths and weaknesses A review of available services and programs within the Fillmore-Houston region demonstrated that many of the region s facilities do provide mammograms (Figure 3.3). However, most of these sites only have access to mobile mammography which may be offered during limited times. In general, access to counseling and other support services is somewhat limited in this region. For example, counseling services are not offered in this region. It should be noted that both Fillmore and Houston Counties are adjacent to areas with many health care resources. Fillmore County is adjacent to Olmsted County, home to Mayo Clinic s main campus in Rochester, Minnesota. Some residents of these counties may receive services at Mayo Clinic. In addition, Gundersen Health System, located in Wisconsin, across the border from Houston County, also offers many services along the continuum of care, including screening, diagnosis, and treatment services. Providers The Community Profile Team gathered surveys from 11 providers in the Fillmore-Houston region. Of the sites included in the provider surveys, 10 identified as Sage providers. All providers in this region were nonprofit agencies. Providers disclosed the payment and reimbursement sources accepted. Nine facilities reported that they accept Medicaid, private insurance, and Medicare. Services are available on a sliding fee scale at one clinic, and six facilities reported charity care programs. The payment and reimbursement sources accepted at two facilities are unknown. Screening, diagnosis and treatment Among the 11 providers who completed surveys in the Fillmore-Houston region, nine provided clinical breast exams. Nine facilities provided some type of mammography services to residents in these counties, seven of which were mobile units. Two providers reported access to digital mammography. All providers in the target counties who do not provide mammography services on-site provide referrals for mammography services. While some providers reported that mammography was available within five miles, four reported that patients had to travel 30 or more miles for mammography services. Some patients may travel as far as 60 miles for those services. Two providers in the Fillmore-Houston region provided image guided breast biopsy. One site offered computer aided detection (CAD) and ultrasound. No facilities in the Fillmore-Houston region reported that they provide treatment services. However, it is likely that residents of this region access Gundersen Health System in Wisconsin, where oncology, chemotherapy, radiation oncology, surgery, reconstructive surgery, and clinical trials are available. Some residents of this county also likely access treatment services at Mayo Clinic s main campus. Education Seven providers in the Fillmore-Houston region provided educational services. Seven facilities reported that they provide breast self-exam training and breast health information. It should be noted that Susan G. Komen does not support the use of breast self-exam training. Rather, Susan G. Komen supports a more comprehensive approach to breast self-awareness, which 53 P age

54 includes knowing one s risk, getting screened, knowing what is normal for the individual, and making healthy lifestyle choices. Five sites reported that they provide community education, and one site had a resource library of educational resources. Counseling and other support services Access to counseling and other support services is somewhat limited in Fillmore and Houston Counties. Five facilities reported that they have nurses or social workers who help patients navigate through screening, diagnosis, and treatment. In addition, three sites reported that they use community health workers who support patients with screening, diagnosis, and treatment. Two sites had patient advocates for financial assistance. Counseling services were not available at any of the facilities in Fillmore and Houston Counties, but are available at the nearby Gundersen Health System in Wisconsin, and at the Mayo Clinic in neighboring Olmsted County. Partnerships and opportunities for collaboration Susan G. Komen Minnesota currently partners with the Sage program, which serves 10 providers in the Fillmore-Houston region. The Affiliate also funds several statewide programs which are available to residents in this area, including Cancer Legal Line. Gundersen Medical Foundation, which serves women in rural Fillmore and Houston Counties, is also a current Affiliate grantee. Gundersen Medical Foundation s project, Breast Health Reaching Women in Rural Communities, provides screening mammograms, diagnostic services, and breast health education to uninsured and underinsured women residing in the rural communities of Fillmore and Houston Counties. Gundersen Health System utilizes its mobile mammography unit to provide screening events in Fillmore and Houston Counties. There may be opportunities to further collaborate with Gundersen Health Systems, which operates five clinics in the target area. Similarly, the Affiliate may consider opportunities to partner with Olmsted Medical Center, which operates four health centers in the region. The Affiliate may also consider ways to partner with providers of counseling services, as no counseling services were identified in this region. 54 P age

55 Figure 3.3. Breast Cancer Services Available in Fillmore and Houston Counties 55 P age

56 Kanabec-Pine Community Health Board Area Health system strengths and weaknesses A review of available services and programs within the Kanabec-Pine region demonstrated that access to screening and treatment services may be somewhat limited in this rural region (Figure 3.4). Several providers in the region provide mammography services, but residents may need to travel 30 or more miles to receive these services. Three facilities in this region provide transportation for screening and treatment. Treatment options in this region are limited. However, it should be noted that many residents of this area may receive care at Mercy Hospital, located in Carlton County just one mile across the border from Pine County. Screening services, including mammography, are available at Mercy Hospital. Mercy also provides several treatment services, including oncology, chemotherapy, and surgery. This region is also located between the Twin Cities metropolitan area and Duluth. Some residents may travel to these larger cities for services. Providers The Community Profile Team gathered surveys from eight providers in the Kanabec and Pine Counties region. Of the sites included in the provider surveys, seven identified as Sage providers. Seven providers in this region were nonprofit, and one was for-profit. Providers disclosed the payment and reimbursement sources accepted: six facilities reported that they accept Medicaid, private insurance, and Medicare, while one facility reported that they have a charity care program. The payment and reimbursement sources accepted at two facilities are unknown. Screening, diagnosis and treatment Among the eight providers who completed surveys in the Kanabec-Pine region, six provided clinical breast exams. Five facilities provided some type of mammography services to residents in these counties, two of which were mobile units. Two providers reported access to digital mammography. Six providers reported that they provide referrals for mammography services. While one provider noted that mammography was available within 15 to 20 miles, five reported that patients had to travel 30 or more miles for mammography services. Some patients may travel as far as 75 miles for those services. One provider in the Kanabec-Pine region offers diagnostic services, including magnetic resonance imaging (MRI), sentinel node biopsy, surgical biopsy, and ultrasound. One facility, FirstLight Health System in Mora, Minnesota, reported that they offer oncology and chemotherapy services. No other facilities in this region offer treatment services. However, treatment services are available at Mercy Hospital in neighboring Carlton County. Education Seven providers in the Kanabec-Pine region provided educational services. Seven sites reported that they provide breast health information, and six reported that they provide breast self-exam training to patients. It should be noted that Susan G. Komen does not support breast self-exam training. Susan G. Komen supports a more comprehensive approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is normal for the individual, 56 P age

57 and making healthy lifestyle choices. Five sites reported that they provide community education, and one site had a resource library of educational resources. Counseling and other support services A variety of counseling and other support services are available at a number of facilities in the Kanabec-Pine region. Six facilities reported that they had nutritional services, four had physical therapy, four had nurses or social workers who help patients navigate through screening, diagnosis, and treatment. Three sites reported that they had patient advocates for financial assistance. Three also had transportation for patients for screening and treatment. One site reported that they use community health workers who support patients with screening, diagnosis, and treatment. One site reported that they have legal services for patients, and one had complementary or alternative therapies available. One site reported that they had side effect management services, and one provided genetic risk counseling and testing. Hospice or palliative care was available at one site. Partnerships and opportunities for collaboration Susan G. Komen Minnesota currently partners with the Sage program, which serves seven providers in the Kanabec-Pine region. The Affiliate also funds several statewide programs which are available to residents in this area, including Cancer Legal Line. The Allina Associated Foundation s Hope Fund is also a current Affiliate grantee. The Hope Fund was initially established to provide emergency financial assistance to qualifying breast cancer patients from a five-county area that includes Pine and Kanabec Counties. Financial assistance provided through the Hope Fund can be used for a variety of purposes, including mortgage payments, groceries, phone or utility payments, gas cards, car repairs, or similar needs. The Affiliate may consider opportunities to collaborate with FirstLight Health Systems, which operates four facilities in the target area. 57 P age

58 Figure 3.4. Breast Cancer Services Available in Kanabec and Pine Counties 58 P age

59 Lincoln-Lyon-Murray-Pipestone-Redwood-Rock (SWHHS) Community Health Board Area Health system strengths and weaknesses A review of available services and programs within the SWHHS region demonstrated that a number of facilities have regular access to mammography services (Figure 3.5). Several facilities also offer treatment services, although the range of treatment services may be somewhat limited. It should be noted that many residents of this area may receive care at Sanford Breast Health Institute, located in Sioux Falls, South Dakota. Sioux Falls is the largest city in the region, and is approximately 30 miles west of Rock County. Providers The Community Profile Team gathered surveys from 22 providers in the Lincoln-Lyon-Murray- Pipestone-Redwood-Rock (SWHHS) region. Five providers in each of Lincoln, Lyon, and Redwood Counties completed the provider survey. Three providers in Pipestone County and two in both Rock and Murray Counties also completed the survey. Of the sites included in the provider surveys, 18 identified as Sage providers. Twenty-one providers in this region were nonprofit agencies. Providers disclosed the payment and reimbursement sources accepted. Twenty facilities reported that they accept Medicaid, private insurance, and Medicare. Seven facilities reported that they have a charity care program, and five offer sliding scale fees. The payment and reimbursement sources accepted at two facilities are unknown. Screening, diagnosis and treatment Among the 22 providers who completed surveys in the SWHHS region, eight provided some type of mammography services, two of which are mobile units. Four providers reported that they provide diagnostic mammography, and three reported access to digital mammography. Seven providers reported that they are able to provide same-day mammograms. Seventeen providers reported that they provide referrals for mammography services. Eleven providers reported that mammography was available within less than 30 miles. Five providers reported that patients had to travel 30 or more miles for mammography services; some patients may travel 70 to 90 miles for those services. Several providers in the region also provide some type of other screening or diagnostic services, including clinical breast exams (n=17), surgical biopsy (n=4), ultrasound (n=4), computer aided detection (CAD) (N=4), image guided biopsy (n=3), and sentinel node biopsy (n=3). Six providers in the SWHHS region reported that they offer treatment services for women who have been diagnosed with breast cancer. These six providers all reported that they have oncology and chemotherapy services, whereas four had surgery and one had radiation oncology services. It should be noted that many residents of the SWHHS region may receive treatment services at the Sanford Breast Health Institute in neighboring Sioux Falls, South Dakota. Education Fifteen providers in the SWHHS region reported that they provide educational services. Thirteen sites reported that they provide breast health information, and 12 reported that they provide breast self-exam training to patients. It should be noted that Susan G. Komen does not support the use of breast self-exam training. Susan G. Komen supports a more comprehensive 59 P age

60 approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is normal for the individual, and making healthy lifestyle choices. Four sites reported that they provide community education. Counseling and other support services Several providers in the SWHHS region reported that they had nurses or social workers (n=9) or community health workers (n=3) who help patients navigate screening, diagnosis, and treatment. Seven providers had a patient advocate for financial assistance. Seven sites offered physical therapy, and five offered nutritional services. Hospice or palliative care was available at four sites. Three sites reported that they offered stress management and coping skills services, and two offered individual counseling or psychotherapy. Two sites offered side effect management. Two sites offered transportation for patients for screening and treatment. One site reported that they had complementary or alternative therapies, and one provided genetic risk counseling and testing. Partnerships and opportunities for collaboration Susan G. Komen Minnesota currently partners with the Sage program, which serves 18 providers in the SWHHS region. The Affiliate also funds several statewide programs which are available to residents in this area, including Cancer Legal Line. The Affiliate may consider opportunities to partner with Avera Medical Group, which operates seven facilities in the region. Similarly, there may be opportunities to collaborate with Sanford Health Systems, which operates five facilities in the target area. 60 P age

61 Figure 3.5. Breast Cancer Services Available in Lincoln, Lyon, Pipestone, Redwood and Rock Counties 61 P age

62 Washington County Health system strengths and weaknesses A review of available services and programs within Washington County demonstrated relatively limited availability of screening and treatment services in relation to the population of the county (Figure 3.6). However, 10 representatives who completed the provider survey were not well informed about their programs services. As such, the services noted in this summary may be an undercount of the services available in Washington County. It should also be noted that Washington County is part of the Twin Cities metropolitan area, a resource-rich area. Many residents of Washington County may have access to resources located throughout the Twin Cities area. Providers The Community Profile Team gathered surveys from 20 providers in Washington County. Of the sites included in the provider surveys, nine identified as Sage providers. Nineteen providers in Washington County were nonprofit, and one was for-profit. Providers disclosed the payment and reimbursement sources accepted. Nineteen facilities reported that they accept Medicaid, private insurance, and Medicare. Six facilities reported that they have a charity care program, and three offer sliding scale fees. The payment and reimbursement sources accepted at one facility are unknown. Screening, diagnosis and treatment Among the 20 providers who completed surveys in Washington County, eight provided some type of mammography services. Seven providers reported access to digital mammography, and four to diagnostic mammography. Seven providers reported that they are able to provide sameday mammography services. Fifteen providers reported that they provide referrals for mammography services. Most providers reported that mammography was available within 10 miles. Several providers in Washington County also provide some type of other screening or diagnostic services, including clinical breast exams (n=15), magnetic resonance imaging (MRI) (n=5), ultrasound (n=6), surgical biopsy (n=3), image guided biopsy (n=3), sentinel node biopsy (n=2), and computer aided detection (CAD) (n=2). Three providers in Washington County reported that they offer treatment services for women who have been diagnosed with breast cancer. These three providers all reported that they have oncology and chemotherapy services. In addition, four providers reported that they have surgery and reconstructive surgery, and one offers clinical trials. It should be noted that some residents of Washington County may receive treatment services in other areas of the Twin Cities metropolitan area. Education Fourteen providers in Washington County reported that they provide educational services. All of these sites reported that they provide breast health information, and 12 reported that they provide breast self-exam training to patients. It should be noted that Susan G. Komen does not support the use of breast self-exam training. Susan G. Komen supports a more comprehensive approach to breast self-awareness, which includes knowing one s risk, getting screened, knowing what is 62 P age

63 normal for the individual, and making healthy lifestyle choices. Four sites had a resource library and three provided community education. Counseling and other support services Among services assessed in the Washington County region, access to counseling and other support services was most limited. Counseling services that were available included individual counseling or psychotherapy (n=3), stress management and coping skills (n=2), side effect management (n=1), genetic risk counseling and testing (n=1), counseling or support group for women with recurrent breast cancer (n=1), counseling or support group for young women with breast cancer, and hospice or palliative care (n=1). Other services available in Washington County included: patient advocates for financial assistance (n=11); nurses or social workers (n=11) or community health workers (n=1) who help the patient navigate through screening, diagnosis, and treatment; complementary or alternative therapies (n=4); nutritional services (n=4); physical therapy (n=4); and legal services. Partnerships and opportunities for collaboration Susan G. Komen Minnesota currently partners with the Sage program, which serves nine providers in Washington County. The Affiliate also funds several statewide programs which are available to residents in this area, including Cancer Legal Line. The Affiliate may consider opportunities to partner with HealthEast, which operates three facilities in Washington County. Similarly, there may be opportunities to collaborate with other providers in the county, such as Allina Health and St. Croix Family Medical Clinic, a clinic of Southside Community Health Services (a Federally Qualified Health Center). The Affiliate may also consider ways to partner with providers of counseling and other support services in the region, as these services were somewhat limited in Washington County. 63 P age

64 Figure 3.6. Breast Cancer Services Available in Washington County 64 P age