Community Health Needs Assessment Report and Implementation Plan Cape Cod Hospital and Falmouth Hospital CAPE COD HEALTHCARE

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1 Community Health Needs Assessment Report and Implementation Plan Cape Cod Hospital and Falmouth Hospital CAPE COD HEALTHCARE

2 For discussion or questions about this report, please contact the Community Benefits Department at Cape Cod Healthcare at Cape Cod Healthcare extends special thanks to Barnstable County Human Services for their assistance throughout this Community Health Needs Assessment

3 DEFINITION AND DEMOGRAPHICS OF THE COMMUNTY SERVED Cape Cod Hospital, Falmouth Hospital and their parent organization, Cape Cod Healthcare, together share the service area of Barnstable County which comprises the geographically isolated region of Cape Cod, approximately 70 miles from Boston, MA. Barnstable County is comprised of 15 towns with a year-round population of 215,888. It is estimated that more than five million visitors come to the area each year, primarily in the summer and fall seasons. Cape Cod Hospital and Falmouth Hospital provide acute care and outpatient services to all communities of Barnstable County. The largest town in the service area is the Town of Barnstable which has over 45,000 year-round residents. The smallest town is Truro, which has 2,000 yearround residents. Current and historical demographic data from the Census department clearly demonstrates a population skewed towards older adults. This population significantly increases the demand for and consumption of healthcare services. Overall, the population of Barnstable County is old and getting older. Seniors, over the age of 65, now represent 25% of the total population. In addition, middle-aged residents known as baby boomers (born between 1946 and 1964) represent another 25% of the Cape population. The County median age grew to 49.9 years in a 12% increase from Comparatively, Barnstable County s median age is more than a decade older than the Massachusetts (MA) and the United States () median age averages. From , the number of residents in Barnstable County over the age of 65 grew by 5%. The most notable change occurred among residents over the age of 85, for which there was growth of 29%. Seniors relying on Social Security income is significantly higher in Barnstable County at 41% compared to 28% for the state and 28% nationally. As baby boomers age into retirement over the next decade, demands on the healthcare system will increase even further. Concurrently, younger residents have migrated out of the service area and birth rates have declined. Barnstable County s overall population declined by 3% from 2000 to 2010, primarily due to an 18% decrease in population of residents aged Annual birth counts in Barnstable County demonstrated a slow but continuous decline between 2000 (1,992) and 2010 (1,711). However, due to earlier birth trends and relocations by families to the Cape during the 1990 s, there has been a net positive increase in residents aged over the past two decades. 1

4 Residents of the Cape cross all economic boundaries, from affluent to economically challenged, vulnerable populations. Recent data estimates from the American Community Survey indicate that the percentage of families living in poverty has increased by 1%, and the percentage of individuals living in poverty has increased by 2% since The most notable increase occurred in children under 18 years old living in poverty, which grew from 6% in 2000 to 12% in Despite growing rates of poverty among some segments, the median household income for Barnstable County increased overall by 32% from $45,933 in 2000 to $60,525 based on a five-year estimate from The median household income for Barnstable County is somewhat greater than the United States ($52,762) but still less than Massachusetts ($65,981). The Cape is home to a broad mix of retirees, working people and the unemployed. Military veterans comprise 14% of the Cape population, versus 8% state-wide. There is a lack of racial and ethnic diversity in Barnstable County. The general race and ethnicity breakdown remains essentially unchanged. Barnstable County is still predominately white, comprising 95% of the total population in 2010, compared to 96% in There have been some incremental increases in minority representations, such as Hispanic and Asian populations. Linguistic challenges have increased over the past decade with more new residents for whom English is not a primary language. Please refer to Appendix D for complete demographic data. COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) Cape Cod Hospital and Falmouth Hospital regularly assess the health needs of Barnstable County residents as part of the strategic planning process and community benefits programming. Recent national healthcare reform legislation, known as the Patient Protection and Affordable Care Act (ACA), created new requirements for non-profit hospitals related to the formal assessment and identification of the needs of the communities they serve (IRS Notice as outlined in section 501(r)(3) of the Internal Revenue Code). The new legislation requires hospitals to conduct periodic community health needs assessments of populations living in their service areas and integrate the findings into actionable and measurable implementation plans. The plan must identify the actions the hospitals will take to address the significant health needs. The regulations did not specify a particular methodology for the assessment, but did require documented community input from key stakeholders and a datadriven approach. Using proposed regulations as a guide, Cape Cod Hospital and Falmouth Hospital jointly initiated this Community Health Needs Assessment. Final IRS regulations are still pending as of August

5 The purpose of this study was to identify the significant health needs of residents of Barnstable County and the community assets available to meet those needs. A related implementation plan has been developed to address those needs. The goals, objectives, initiatives, resources and potential collaborators included within the Implementation Plan will guide the annual planning of Community Benefits initiatives and hospital-based community service programs for Cape Cod and Falmouth Hospital. The framework of this plan spans Fiscal Years The objectives of the CHNA were: To gather statistically valid information on the health status of the residents of Barnstable County, To develop accurate comparisons to state and national benchmarks of health and quality of life measures to provide trending information for the future, To identify key areas of significant community needs and vulnerable populations, To integrate research findings into community benefit and hospital planning activities and To meet all IRS requirements related to the needs assessment. Holleran Consulting Group, an independent research firm experienced in conducting community health needs assessments, was selected to assist Cape Cod Hospital and Falmouth Hospital in conducting objective primary research. The firm conducted a household telephone survey and facilitated five focus group discussions among key stakeholders. The groups were held at Cape Cod Hospital and Falmouth Hospital to accommodate geographic distribution. In addition, Holleran Consulting Group worked with the Community Benefits team to collect state and national data which was utilized in comparison to County and hospital data. The telephone survey, aimed at the general public, yielded a statistically relevant sample of 464 residents. The survey instrument was adapted from the Centers for Disease Control and Prevention s Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is recognized as a leading tool to assess health conditions and behavioral risk, and is widely employed by public health agencies. The format allows for comparisons of the health conditions of Barnstable County residents with MA and populations on issues such as healthcare access, chronic and infectious disease screenings, oral health, and anxiety and depression. Survey respondents included adults over the age of 18 living in a residence, but excluded persons living in prisons and group home facilities. As part of the study, Cape Cod Hospital (CCH) and Falmouth Hospital (FH) collaborated with Barnstable County Human Services (BCHS) to research the health status of Cape Cod residents. Utilizing the BRFSS system, BCHS provided key analyses of comparative data of the service area and state, and prepared a report of trended data for This data was fundamental to understanding current health status, spotlighting variances, and identifying trends for declines or improvements within the community. 3

6 BCHS also assisted CCH and FH in identifying participants for the focus groups, community forums and key informant interviews which were conducted over the course of the study. Community Benefits staff conducted over 20 one-on-one interviews with key informants to explore significant health needs, activities, barriers, gaps and solutions. This broad-based community research was designed to solicit information on priority health issues affecting medically underserved, lowincome and vulnerable populations, and to identify gaps in services and opportunities for collaboration. Primary research data was heavily augmented with secondary data from national, state and regional sources. The most current Barnstable County health data available was collected, analyzed and synthesized, and then compared to MA and data as available. Data collection efforts focused on demographic characteristics, behavioral risk factors associated with health status, disease incidence and prevalence rates, access to care, health status indicators, morbidity/mortality, and hospital utilization. More than 80 community organizations participated in the Community Health Needs Assessment (listed below). These groups represented a wide range of vulnerable populations and conditions, including: Chronically ill Disabled Medically underserved Uninsured Low-income families Homeless individuals Mental Illness Substance abuse Seniors Youth and young adults Immigrant populations Lesbian, gay, bi-sexual or transgendered (LGBT) In June 2013, upon completion of the primary and secondary research, Cape Cod Hospital and Falmouth Hospital hosted two community forums. All stakeholders who had collaborated in the CHNA were invited to participate. Community leaders, advocates and public health experts representing health and human service agencies from across Cape Cod attended the forums. CCH and FH presented the CHNA study methodology and draft findings at both sessions and facilitated an open and candid dialogue among the attendees. The presentation focused on the significant health needs identified, discussion of existing needs, gaps in service and collaborative approaches to address these needs. Feedback and input from the community forum attendees was used to inform the prioritization of the significant health needs in this report. 4

7 Public health experts, health care providers and health service organizations: AIDS Support Group of Cape Cod Emerald Physicians American Cancer Society Falmouth Human Services Barnstable County Public Nurse Harbor Community Health Center-Hyannis Barnstable County Human Services Hope Health CCHC Diabetes Education Services HOPE Dementia & Alzheimer s Services of Cape Cod CCHC Emergency Services Lyme Awareness of Cape Cod CCHC Infectious Disease Clinical Services Medical Affiliates of Cape Cod (MACC) CCHC Regional Cancer Network National Multiple Sclerosis Society Cape Cod Human Services Oral Health Excellence Collaborative Cape Disability Network Outer Cape Health Services CCH Patient and Family Advisory Committee Parish Nurse Ministries of Cape Cod Cape & Islands Emergency Medical Services System Samaritans on Cape Cod and Islands Community Health Center of Cape Cod (CHCCC) South Bay Mental Health Cape Cod Medical Reserve Corp Specialty Network for the Uninsured Duffy Health Center VNA of Cape Cod Organizations serving low-income, medically underserved or vulnerable populations: Barnstable School System Freedom from Addiction Network Big Brother Big Sister of Cape Cod & the Islands Gosnold on Cape Cod Bourne Council on Aging Health Imperatives Boys & Girls Club of Cape Cod Hyannis Family Planning Cape Cod Healthy Families Helping Our Women Cape Cod Immigration Center Hyannis Youth and Community Center Cape Cod Justice for Youth Collaborative Kennedy Donovan Center Cape Cod Justice for Youth Board Lower Cape Outreach Council Cape Cod WIC Mashpee Council on Aging Cape Cod Neighborhood Support Coalition Provincetown Council on Aging Cape & Islands Gay Straight Youth Alliance REACH Program of Cape & Islands EMS System CHAMP Homes Sandwich Council on Aging Child and Family Services SHINE (Serving Health Information Needs of Everyone) Children s Study Home St. John s Episcopal Community Youth Project COAST (COA s Serving Together) Truro Council on Aging County Network of Cape Cod Visiting Nurse Association of Cape Cod Elder Services of Cape Cod & the Islands Women and Adolescent Health at CHCCC Falmouth Prevention Partnership Veterans Outreach Center Falmouth Service Center YMCA of Cape Cod County, town, or municipal entities and regional task forces: Barnstable County Human Rights Commission Falmouth Housing Authority Cape & Islands United Way Falmouth Police Department Cape Cod Center for Women MA Department of Mental Health Cape Cod Community College Mashpee Housing Authority Cape Cod District Attorney s Office Maternal Depression Task Force Cape Cod Foundation Sandwich Housing Authority Cape & Islands Suicide Prevention Coalition Youth Suicide Prevention Project Cape Cod Council of Churches 5

8 DATA SOURCES UTILIZED Cape Cod Hospital and Falmouth Hospital Utilization Data: Information including utilization of inpatient, outpatient and emergency services, and patient demographics Falmouth Prevention Partnership Community Profile on Youth Substance Abuse in Falmouth 2009 Tri-County Collaborative for Oral Health Excellence (Tri-CCOHE) 2010 Evaluation Report: Information based on surveys related to oral health in Barnstable County Massachusetts Department of Public Health (MDPH) Massachusetts Community Health Information Profile (MassCHIP): Communitylevel data to assess health needs and health status indicators for counties in MA Bureau of Substance Abuse Services (BSAS): Substance abuse treatment statistics for towns and counties in MA Massachusetts Department of Elementary and Secondary Education: Data on enrollment and student demographics from schools and districts in MA Massachusetts Department of Labor and Workforce Development: Data related to employment, job status, and wages and earnings for MA Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS) , prepared by Barnstable County Human Services: Data for behavioral health risk factors such as healthcare access, immunizations, disability, and chronic disease. Youth Risk Behavioral Surveillance System (YRBSS): Monitors risk behaviors among youth and adults such as unintentional injuries and violence, sexual behaviors and sexually transmitted diseases, alcohol and drug use, tobacco use, obesity, and physical activity. National Center for Health Statistics: Data to identify and address health issues such as healthcare access, health disparities, and health status indicators. National Program of Cancer Registries: A collective of local cancer registries created to enable public health professionals to better understand and address the cancer burden more effectively across the. Centers for Disease Control and Prevention WONDER Database: A data system that makes the public health information resources of the Centers for Disease Control and Prevention available to public health professionals and the public at large. 6

9 Healthy People 2020: A government-led, national health effort to set 10-year national health improvement objectives for all residents of the. Benchmarks are established and monitored over time to encourage collaboration across communities, empower individuals to make informed health decisions and measure the impact of disease prevention activities. Census Bureau Census 2000 and Census 2010: Comprehensive population data including gender, household size, family and relationships, housing units, race and origin groups, and income. American Community Survey: An ongoing survey that provides data each year on information such as gender, race, family and relationships, income and benefits, health insurance, education, and employment. Department of Veteran Affairs: Key statistics on Veteran populations and Veteran programs. Please refer to Appendix C for more information regarding study methodology. See Appendix K for the complete Barnstable County Human Services Behavioral Risk Factor Surveillance Systems Report, INFORMATION GAPS Despite the extensive data collection, there was a notable gap in this assessment related to the health status of tribal populations in Barnstable County. The Hospitals are currently engaged with the newly-formed Indian Health Services Clinic. Information gathered by the clinic will be incorporated into hospital planning activities on an ongoing basis. 7

10 IDENTIFICATION AND PRIORITIZATION OF SIGNIFICANT HEALTH NEEDS IRS guidelines instruct hospitals to identify and prioritize significant health needs in their community. The significant health needs of Barnstable County were identified through extensive quantitative and qualitative data assessments. Specific needs were distinguished and then prioritized based on the frequency, urgency, scope, severity, and magnitude of the identified issues. These significant health need priorities are the foundation on which the Implementation Plan and corresponding strategies and initiatives are based. I. Chronic and Infectious Diseases Cancer and cardiovascular disease, respectively, remain the top two causes of death in Barnstable County and the state. Mortality rates for both are declining in Barnstable County. National data places cardiovascular disease as the leading cause, followed by cancer. Cancer mortality rates for Barnstable County (173) mirror that of MA (174) and the (174). 1 Although cancer death rates have trended down since 2000, the overall incidence of cancer in Barnstable County (567) is higher than MA (514) and the (472). Specifically, prostate cancer is higher in Barnstable County (190) than MA (156) and the (149); invasive breast cancer in Barnstable County (169) is higher compared to MA (141); and the rate of melanoma/skin cancer in Barnstable County (39) is higher than both MA (23) and the (19). The cardiovascular disease mortality rate significantly declined from 2000 (182) to 2009 (150) despite an upward trend from the lowest rate in 2007 (127). The 2009 cardiovascular disease mortality rates in Barnstable County (150) were consistent with rates in MA (154) and compared favorably to rates in the (183). 2 Rates of HIV/AIDS, chlamydia and Lyme disease are on the rise in Barnstable County, which has drawn increased attention towards infectious disease. The prevalence rates of HIV/AIDS in Barnstable County increased from 2000 (188) to 2009 (268). 3 In 2009, Lyme Disease incidence rates were significantly higher in Barnstable County (82) compared to MA (62), and although the incidence rate of chlamydia is lower in Barnstable County than in MA, the incidence rates in 2000 (52) more than tripled by 2010 (163). 4 1 Cancer and cardiovascular disease mortality rates are age-adjusted rates per 100,000 persons. 2 Cardiovascular disease mortality rates are age-adjusted rates per 100,000 persons. 3 HIV/AIDS prevalence rate are rates per 100,000 persons. 4 Lyme disease and sexually transmitted disease incidence rates are rates per 100,000 persons. 8

11 Other notable diseases of concern include: Alzheimer s disease-related deaths nearly doubled between 2001 (83) and 2010 (159). 5 Diabetes mortality rate is highest amongst those 75 years and older, but total mortality rates are lower in Barnstable County (11) than MA (13) and the (21). Dental disease/oral health is linked to income, age and preventive care according to the Behavioral Risk Factor Surveillance System. 6 Parkinson s disease mortality rates are higher in Barnstable County (7.4) than MA (5.6) or the (6.5). Awareness and utilization of preventive and maintenance healthcare services were recognized as challenges related to chronic and infectious disease. Specific populations, such as those with physical and developmental disabilities, were identified as populations that are especially likely to develop complex needs over time such as dementia, cardiovascular disease and diabetes. Although mortality rates for cancer and cardiovascular disease have been on a downward trend, the prevalence of these diseases remains high. Accordingly, treatment of these agerelated conditions increases demands on both Cape Cod Hospital and Falmouth Hospital, as well as other health providers in the region. In addition, other chronic and infectious diseases create additional system demands. Chronic and infectious disease care and management will remain at the forefront of the Hospitals strategic plans, service line development, and community efforts. Please refer to Appendix E for the data tables associated with chronic and infectious diseases. 5 Alzheimer s disease total death counts for Barnstable County 6 Appendix K, Behavioral Risk Factors Surveillance System (BRFSS)

12 II. Access to Care The Needs Assessment revealed that barriers to care still exist despite state-mandated expansion of health insurance. Chief among these challenges are availability of certain providers, out-of-pocket costs, uneven knowledge of available services and linguistic challenges. The high rate of insurance coverage among Massachusetts residents is generally reflected in Barnstable County. Public data estimates that approximately 93% of residents have some type of health insurance coverage. Many community advocates note that this number may be understated as it is not inclusive of immigrant and other vulnerable populations that fall outside traditional recording methodologies. Since 2006, when the MA legislature passed the first significant healthcare reform measures, there have been significant efforts in the community, at health centers and in the hospitals to enroll uninsured residents in coverage. These efforts continue in the community today, supported by federal funding from the ACA and Community Benefits grants made by hospitals across the Commonwealth and here on Cape Cod. Notably, Barnstable County residents are more likely to rely on public health insurance, including Medicare and Medicaid. Data shows that 43% of Barnstable County residents are covered by public payers, compared to 33% for MA and 31% for the. Cape Cod Hospital and Falmouth Hospital financial data show that more than 67% of patient service revenues come from public payers. CCH and FH are recognized statewide as especially dependent upon Medicare revenue. Feedback from the resident telephone survey indicates that co-payments, deductibles and high prescription costs present financial challenges even to those residents who have health insurance. Community health experts confirm that economically challenged individuals, seniors, immigrants and young people who have aged out of their parents health plans often have difficulty accessing and paying for healthcare. Finally, the CHNA study highlighted the issue of provider availability. Provider recruitment efforts by CCH, FH, the four federally qualified health centers and private physician groups were recognized during the Needs Assessment. However, challenges still remain in terms of access to primary care physicians and certain specialists such as dermatologists, endocrinologists and psychiatrists.. Please refer to Appendix F for data tables associated with Access. 10

13 III. Mental Health Access to adequate mental healthcare is an area of concern in Barnstable County, as evidenced by an increase in suicide rates and the high number of patients presenting with mental health disorders in hospital emergency centers. A shortage of psychiatric providers and limited acute care institutional options adds to this concern. Barnstable County s annual suicides nearly doubled from 2000 to 2009 from 14 to 26 per year. The number of patients seen and diagnosed with mental disorders has increased significantly in the Emergency Centers of both Cape Cod Hospital and Falmouth Hospital since Stress-related concerns continue to increase. Sixteen percent of respondents to the household telephone survey reported that they have been told by a healthcare professional that they had a stress or anxiety disorder, compared to 13% reported in national studies. The need for access to mental health services across Barnstable County emerged as an area of significant need throughout the study. The stigma of mental illness, the shortage of psychiatric providers, the lack of integration with primary care, and the need for greater suicide education and prevention were identified through community input. Advocates for the veteran community suggest that there is a lack of adequate mental health services for the County s veterans. It is anticipated that demand for veterans access to health services will remain high due to traumatic psychological and physical injuries. The detection, treatment and support of individuals and families with mental illness is a complex issue that requires application of broad-based resources across the community. Please refer to Appendix G for the data tables associated with the significant health need. IV. Substance Abuse Substance abuse treatment admissions are on the rise. Overall rates of substance abuse treatment admissions are higher in Barnstable County (2,282) than MA (1,590). 7 Specifically, treatment admissions for alcohol as a primary substance are more than 10% higher in Barnstable County (51%) than MA (39%). The rates of treatment admissions for other opiates as a primary substance grew from 11% in 2007 to 28% in Law enforcement and EMS leaders note a disturbing increase of heroin use among young people. Numerous challenges were identified, including limited availability of detox and treatment options, the limited detection of substance abuse in the primary care setting, difficulty navigating existing services, and the increased use of marijuana. 7 Substance abuse treatment rates are rates per 100,000 persons. 8 The 2011 definition used by the Bureau of Substance Abuse Services (MA Department of Health) for other opiates includes non-prescription methadone, non-prescriptions opiates, oxycodone and prescription opiates. 11

14 Data indicates that the abuse of both legal and illegal drugs is an area of concern for residents of Barnstable County. Prescription medication dependence is on the rise, particularly the abuse of prescription opiates. The hospitals have set goals in the Implementation Plan to respond to these concerns through a broad network of community engagement. Please refer to Appendix H for the data tables associated with this significant health need. V. Senior Health Challenges There is an increased demand for healthcare services in Barnstable County due to the region s senior population. Seniors who live longer are more likely to face chronic disease and utilize health services with more frequency. They are also more likely to require home care and potentially skilled nursing or long-term care. Increasing rates of neurological disease, such as Alzheimer s, also increase demands on care givers. Twenty-nine percent of Barnstable County household telephone survey respondents reported that they provide care or assistance to friends or family members, compared to 18% in MA. Additionally, 38% of those respondents indicated that their role as caregiver creates stress. Nearly 40% of all households in Barnstable County include a resident over the age of 65, compared to approximately 26% of households in MA and the. The rate of male and female residents over the age of 65 who live alone increased from Data indicates that this population has a potential increased risk of isolation, depression and/or injury. Elderly patients can be particularly vulnerable after a hospital stay. CCH and FH provide case management and social services to patients and families to ease this transition. Additionally the hospitals have made investments in home-based programs to support high risk patients with reconciliation of prescription medications after discharge. Please refer to Appendix I for the data tables associated with this significant health need. 12

15 VI. Youth and Young Adult Health Community input and data collection identified adolescents (aged 15-19) and young adults (aged 20 24) as particularly vulnerable populations in Barnstable County. Risky behaviors and poor health decisions was shown to have increased in both groups. Community input identified the following contributing factors: Lack of access to and lack of availability of structured activities Lack of supervision and engaged parenting Lack of role models who provide guidance on healthy behavior and decision-making Missed opportunities for early education or intervention in school-based programs Lack of community-based prevention education programs Risky behavior has resulted in high rates of motor vehicle accidents, substance abuse treatment admissions and sexually transmitted diseases among year-old residents of Barnstable County. In 2010, the substance abuse treatment admissions rates for adolescents aged in Barnstable County (3,522) were more than double that of MA (1,043). The same is true for young adults aged in Barnstable County (9,200) compared to rates in MA (4,008). 9 Hospitalizations due to motor vehicle accidents in 2009, for residents aged 15 to 19 years old, in Barnstable County (165) were double those of MA (81). 10 Hospitalization rates due to motor vehicle accidents for young adults aged 20 to 24 years old in Barnstable County (275) were significantly higher than MA (112) in Rates of chlamydia diagnoses in youth and adolescents have increased significantly since In adolescents ages 15 19, the incidence rates in Barnstable County more than tripled from 2002 (267) to 2010 (826). For young adults ages 20 24, the rates increased significantly since 2000 with the largest increase from 2003 (273) to 2010 (1142). 11 Cape Cod Hospital and Falmouth Hospital will support community programming to enhance education and intervention related to these issues. Please refer to Appendix J for the data tables associated with this significant health need. 9 Substance abuse treatment admission rates for adolescents and young adults are age-specific rates per 100,000 persons. 10 Hospitalization rates are age-specific rates per 100,000 persons. 11 Sexually transmitted disease rates are age-specific rates per 100,000 persons. 13

16 EXISTING HEALTHCARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY In addition to identifying the significant health needs in Barnstable County, this assessment helped identify the vast array of services currently available to address these needs. Cape Cod Hospital and Falmouth Hospital are part of a group of inter-connected community organizations (noted below) that work collaboratively in the service area. Please refer to Appendix B for a list of existing healthcare facilities and resources in the community whose work addresses the significant health needs identified in this assessment. Cape Cod Healthcare: Cape Cod Hospital and Falmouth Hospital provide acute inpatient, outpatient, surgical and diagnostic care to residents of Barnstable County and visitors. Key service areas include Behavioral Health, Cardiovascular, Infectious Disease, Imaging, Lab and Blood Donor Services, Maternity, Medical, Neuroscience and Pain, Oncology, Orthopedics, Rehabilitation, Surgery, and Wound Care. Cape Cod Healthcare, Cape Cod Hospital and Falmouth Hospital offer ambulatory services at satellites located throughout the service area. Currently, six health centers provide primary care, specialty care, urgent care, lab, imaging and rehabilitation services in outpatient settings. In addition to the two hospitals, the Cape Cod Healthcare system includes other affiliates such as Visiting Nurse Association of Cape Cod, C-Lab, JML Care Center, Heritage at Falmouth, Cape Cod Human Services and the Medical Affiliates of Cape Cod. The Visiting Nurse Association of Cape Cod provides home care, hospice care, and palliative care to residents of Barnstable County. Among other services, the VNA provides home health visits to ensure smooth transitions from hospitals or skilled nursing facilities to home. C-Lab is the largest clinical lab in the service area with 14 locations across Barnstable County. Each location is a patient service site dedicated to phlebotomy and specimen collection. JML Care Center is a skilled nursing facility in Falmouth that specializes in orthopedics, cardiology, pulmonary, neurology/stroke, and complex medical rehabilitation and therapeutic care. Heritage at Falmouth is Cape Cod Healthcare s 56-room assisted living facility located on the Falmouth Hospital campus. It offers residents easy access to care facilities including the Hospital, medical offices, C-Lab, JML Care Center, and the Visiting Nurse Association of Cape Cod. Cape Cod Human Services provides extensive outpatient psychiatric evaluation and services to children, adolescents and adults. The Medical Affiliates of Cape Cod is the Cape Cod Healthcare employed physician group which has over 30 primary and specialty care practices across the service area. 14

17 Federally Qualified Community Health Centers: Barnstable County has four federally-qualified and funded health centers. They are the Community Health Center of Cape Cod, Duffy Health Center, Harbor Community Health Center Hyannis, and Outer Cape Health Services. Cape Cod Healthcare, Cape Cod Hospital and Falmouth Hospital work collaboratively with these health centers and provide annual support for initiatives and programs that align with Cape Cod Healthcare s Community Benefits priorities. Community Health and Human Service Organizations: Barnstable County has a strong and diversified sector of community organizations that provide critical health and human services to residents of the service area. Cape Cod Hospital and Falmouth Hospital provide annual support to numerous organizations through a competitive grants process. Additionally, the Hospitals develop and collaborate on impactful projects aimed at targeted populations. NEEDS NOT ADDRESSED There were challenges identified in this assessment that fall outside of the core competencies of the two hospitals. These include lack of transportation, homelessness, unemployment, domestic violence and sexual assault. These needs, while quite important to the community, are outside the scope of significant health needs which the Hospitals can reasonably address. They are excluded from the CCH and FH Implementation Plan. Cape Cod Hospital and Falmouth Hospital will rely on other organizations to address these challenges. Outlined below are the specific organizations identified in the community that are working to address these important issues. Transportation Barriers: While transportation was identified as a barrier to obtaining health care services, solving systemic transportation issues requires the skills of organizations such as the Cape Cod Regional Transit Authority (CCRTA) and the Cape Cod Commission who are leading regional efforts to improve transportation in our region. Homelessness: Community input also identified homelessness as a barrier to obtain healthcare services. Cape Cod Hospital and Falmouth Hospital are committed to serving homeless individuals/families in need of acute, primary, specialty, or behavioral health services. Organizations such as Housing Assistance Corporation, Duffy Health Center, Lower Cape Outreach Council, Regional Network to End Homelessness, and regional/town housing authorities lead key efforts to help eliminate housing barriers in the service area. Employment Status: Experiencing unemployment or vulnerability related to job status was identified as a barrier to obtaining healthcare. The skills needed to solve systemic employment issues are better aligned with organizations such as Career Opportunities, and Job Training and Employment Corporation. These agencies will lead efforts to remove barriers to sustainable employment. Domestic Violence and Sexual Assault: As frontline community health providers, the staff at Cape Cod Hospital and Falmouth Hospital plays a vital role in responding to the emergency health needs of victims of domestic violence and sexual assault, in partnership with public safety officials and community-based service providers. The Hospitals rely on the expertise of agencies such as the Cape Cod Center for Women, Children s Cove, and Independence House to provide community leadership on issues related to the education, intervention and prevention of domestic violence and sexual assault. 15

18 SUMMARY OF PRIORITIES AND TARGET POPULATIONS The six significant health needs identified in the CHNA span demographics, populations and the geography of Barnstable County. Chronic and infectious diseases present clear challenges that have a significant impact on the community and health providers. Barriers to care still exist despite high rates of insured residents. Mental health continues to be a challenging issue of need and response, and substance abuse trends are rising at an alarming rate. There are specific challenges related to the growing senior population, as well as youth and young adult health and risk-related behaviors. In summary, there are critical issues that need to be addressed to improve the well-being of Barnstable County residents. Cape Cod Hospital and Falmouth Hospital will focus their Community Benefits efforts on addressing these six priorities over the next three years. Initiatives will focus on corresponding target populations that were identified in this Needs Assessment. FY2014 FY2016: 1. Support community-based activities to improve chronic and infectious disease management. 2. Expand access to healthcare services to reduce health disparities and promote health equality. 3. Support programs for outreach, education, navigation and intervention targeted at individuals and families facing mental health issues. 4. Support community-based substance abuse prevention and intervention programs. 5. Support programs that address senior health challenges. 6. Support community-based programs that encourage positive health and lifestyle choices by youth and young adults. Target Populations Residents managing chronic diseases or those at-risk of developing chronic diseases Uninsured and under-insured residents Residents facing barriers to care due to language, cost, or age Individuals and families navigating mental health services Isolated residents over the age of 65 at a high risk for depression and injury At risk youth and young adults, especially residents aged

19 CAPE COD HOSPITAL AND FALMOUTH HOSPITAL GOALS AND STRATEGIES The priorities and associated target populations that were identified in the community health needs assessment will be the foundation for community benefits programming and hospital planning for the next three years. Cape Cod Hospital and Falmouth Hospital, through their Community Benefits program, will build an agenda aimed at developing these important healthcare services and community-based programs. Cape Cod Hospital and Falmouth Hospital will jointly address identified needs through initiatives outlined in the Implementation Plan The Implementation Plan will be further defined, updated and evaluated over the course of this planning cycle. Annual ongoing program evaluation and identification of emerging trends and needs will guide any changes to strategy and tactics. Outcome measures will be reported and addressed. The goals outlined in the Implementation Plan will be accomplished through the following: Hospital-Based Programs and Community Support Cape Cod Hospital and Falmouth Hospital will continue to support existing programs that are aligned with identified needs. New program development will also be aligned with defined priorities and target populations. Cape Cod Hospital and Falmouth Hospital will provide staff and resource support for organizations across the service area through partnerships, in-kind services and participation in county-wide coalitions. Collaboration with dedicated and knowledgeable organizations will be an essential driver of services. Community Benefits Planning and Resource Allocation Cape Cod Hospital and Falmouth Hospital will jointly leverage system-wide Community Benefits planning and resources. Efforts will include annual support and/or funding through competitive grants processes, and ongoing partnerships and collaboration with state and local health organizations. Cape Cod Hospital currently provides funding to the Cape Cod Community Health Network Area (CHNA 27), as specified through a Determination of Need (DoN) requirement. Funds are awarded via CHNA 27 and their fiscal agent to non-profit organizations that are focused on improving the health of Barnstable County residents, specifically focused on seniors and individuals with disabilities. The DoN funding allocations began in 2010 and will continue through CCHC Community Benefits staff is also engaged with CHNA 27 as a member of the Steering Committee, and participates in Barnstable County Human Services Advisory Council to address regional needs. 17

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21 CAPE COD HOSPITAL FALMOUTH HOSPITAL JOINT IMPLEMENTATION PLAN FY14-FY16

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23 I. Chronic and Infectious Diseases Priority: Support community-based activities to improve chronic and infectious disease management. Goal FY14-16: Improve chronic and infectious disease management to meet the growing needs of an aging and at-risk population. Objectives FY14-16: Reduce risk of hospitalization and readmission for residents with chronic and infectious disease Increase outreach, education, screening and detection services to at-risk populations Align existing initiatives and clinical affiliations to meet needs associated with identified diseases of concern Strengthen connections between clinical and community-based services Initiatives FY14-16: I. Support community-based organizations with programs designed to improve chronic or infectious disease management through the annual Community Benefits grant program II. Expand and develop existing hospital-based initiatives that provide cancer survivorship activities and support, diabetes education services, cardiac and pulmonary rehabilitation, HIV/AIDS, and sexually transmitted disease monitoring III. Provide support to patients managing complex chronic and infectious diseases through the Complex Care Program. Provide patient/family education, medication management, and referrals to appropriate therapeutic services and care planning in coordination with primary care providers IV. Partner with community-based organizations to provide clinical outreach, education, and/or resources to improve prevention, risk, screenings, and detection of infectious diseases such as HIV/AIDS, Hepatitis C, and sexually transmitted diseases V. Strengthen strategic clinical affiliations to increase capacity to address chronic diseases Expected Outcomes FY14-16: Community Benefits grants will support community efforts to manage chronic and infectious diseases. The Complex Care Program will provide support to a greater number of high-risk patients. Clinical staff will work with community-based organizations to provide education and outreach related to chronic disease. High-risk residents will receive vital screening and testing for HIV, Hepatitis B & C, and sexually transmitted diseases. Existing clinical affiliations will be built upon to expand access to chronic disease care. Facilities and Resources: Cape Cod Hospital and Falmouth Hospital each will commit staff, financial resources and Community Benefits funding to support these initiatives. Continuous evaluation and planning of initiatives will guide ongoing resource allocation from each facility and will inform annual Community Benefits planning and funding initiatives. Resources from Cape Cod Hospital, Falmouth Hospital, and the affiliate programs, services, and agencies of Cape Cod Healthcare will be coordinated to support key initiatives related to chronic disease. Potential Collaborators: AIDS Support Group of Cape Cod, Barnstable County Human Services, Cape Cod Extension Services, Cape Cod Health Network ACO, Cape Cod Healthcare s Diabetes Education Services, Cape Cod Healthcare s Infectious Disease Clinical Services, Cape Cod Healthcare s Regional Cancer Network, Health Imperatives Hyannis Family Planning, Hope Dementia and Alzheimer s Services of Cape Cod and the Islands, Lyme Awareness of Cape Cod, MA Department of Public Health, Visiting Nurse Association of Cape Cod, and other relevant community organizations. 18

24 II. Access to Care Priority: Expand access to healthcare services to reduce health disparities and promote health equality. Goal FY14-16: Expand access to healthcare services for all residents of Barnstable County, especially vulnerable populations. Objectives FY14-16: Increase availability of primary care and specialty providers in the service area Strengthen collaboration between hospitals and community health centers to achieve common goals for both access and coordination of care Support efforts to increase health insurance enrollment and re-enrollment Support access to care for residents who encounter barriers due to linguistic challenges and financial hardships Initiatives FY14-16: I. Support community-based programs that expand access to health services for vulnerable populations through the annual Community Benefits grant program II. Assess annual needs of Community Health Centers within service area and align collaborative efforts and Community Benefits funding to projects that impact vulnerable populations and achieve common goals III. Recruit providers for primary care and defined specialties based on annual physician needs assessment of service area. All hospital and Cape Cod Healthcare-employed physicians will be required to accept all public insurance plans, further reducing barriers to care for vulnerable populations IV. Provide hospital-based programs such as telephone access lines, online physician-finder tools, financial counseling, assistance with insurance enrollment/re-enrollment, and community-based interpreter services to assist residents in accessing and navigating available resources V. Provide hospital-based services such as prescription assistance, transportation vouchers, and social service referrals to vulnerable populations upon discharge Expected Outcomes FY14-16: Community Benefits grants will support Community Health Centers and community-based organizations working to expand access to vulnerable populations. Primary care providers and specialists will be recruited based on annual recruitment goals. Residents will receive assistance in navigating available services through phone-based and online support. Cape Cod and Falmouth Hospitals will provide financial counseling and insurance enrollment assistance to residents of the service area. Individuals with linguistic barriers to care will receive interpreter services in their physicians offices. Access to a specialist s network will be coordinated and offered to uninsured or underinsured residents. Facilities and Resources: Staff, financial resources, and Community Benefits funding will be allocated to support these critical initiatives by both Cape Cod Hospital and Falmouth Hospital. Hospital staff will play a critical role in the annual impact assessment of initiatives and evaluation of emerging needs. Potential Collaborators: Barnstable County Human Services, Community Action Committee of Cape Cod & Islands, Community Based Interpreter Services, Community Health Center of Cape Cod, Duffy Health Center, Harbor Community Health Center - Hyannis, Helping Our Women, Lower Cape Outreach Council, MA Department of Public Health, Outer Cape Health Services, SHINE, Specialty Network for the Uninsured, and other relevant community organizations. 19

25 III. Mental Health Priority: Support programs for outreach, education, navigation, and intervention targeted at individuals and families facing mental health issues. Goal FY14-16: Support collaborative efforts to strengthen outreach, education, and navigation of services available to individuals and families facing mental health issues. Objectives FY14-16: Align hospital and community-based services to strengthen mental health continuum of care in Barnstable County Support regional efforts to provide community-based mental health assistance, referral and assessment Support community-based initiatives targeted at individuals and families facing mental health issues Initiatives FY14-16: I. Support community-based programs that expand access, education, and navigation of mental health services through the annual Community Benefits grant program II. Clinical and Community Benefits staff will participate in regional behavioral health task forces and coalitions to improve communication and collaboration between mental health providers III. Emergency phone consultations, behavioral health assessments in Cape Cod Hospital and Falmouth Hospital Emergency Centers, and assistance in navigating community-based resources will be provided 24 hours per day, 7 days per week by a clinical Psychiatric Assessment Team to assist individuals, families, and community members IV. Community Benefits staff will participate in coordinated efforts to strengthen connections between Cape Cod Healthcare Behavioral Health Services, Cape Cod Human Services, the Emergency Center s at Cape Cod Hospital and Falmouth Hospital, and community organizations with the goal to improve access and coordination of mental healthcare for patients Expected Outcomes FY14-16: Community Benefits grants will fund efforts related to navigation, access, and education of mental health services. Clinical and Community Benefits staff will participate on the Behavioral Health Steering Committee and assist in coordination of the Cape Cod First Annual Behavioral Health Summit. A clinical Psychiatric Assessment Team (PAT) will provide assessments in hospital Emergency Centers and will provide phone-based referral, assistance, and navigation to residents in need of mental health services. Facilities and Resources: Cape Cod Hospital and Falmouth Hospital will allocate Community Benefits funding, staff and financial resources to improve mental health services in our service area. Cape Cod Hospital will play a predominant role in facilitating initiatives due to facility proximity to community based services and coordination with on-site Psychiatric Center at Cape Cod Hospital. Resources from Cape Cod Hospital, Falmouth Hospital and the affiliate programs, services and agencies of Cape Cod Healthcare will be coordinated to support key initiatives related to mental health. Potential Collaborators: Barnstable County Human Services, Cape Cod Behavioral Health Steering Committee, Cape and Islands Suicide Prevention Coalition, Cape Cod Council of Churches, Cape Cod Healthcare s Behavioral Health Services, Cape Cod Human Services, Community Health Center of Cape Cod, Harbor Community Health Center Hyannis, MA Department of Public Health, MA Department of Mental Health, National Alliance on Mental Illness, Outer Cape Health Services, and Samaritans of Cape Cod and the Islands, and other relevant community organizations. 20

26 IV. Substance Abuse Priority: Support community-based substance abuse prevention and intervention programs. Goal FY14-16: Support community-based strategies to address the prevention and intervention of substance abuse in Barnstable County. Objectives FY14-16: Efforts to develop and implement new strategies in substance abuse education, prevention, and intervention across Barnstable County Partner with key community stakeholders to evaluate the effectiveness of existing efforts and initiatives to address substance abuse Support regional efforts to assess the impact of current substance abuse trends in Barnstable County Support community-based programs that address substance abuse Initiatives FY14-16: I. Support community-based programs that address the prevention and intervention of substance abuse through the annual Community Benefits grant program II. Community Benefits will contribute to regional efforts to develop leadership, best practices, innovative models, and evaluation of substance abuse prevention strategies III. Collaborate with key community stakeholders such as individuals, health and community organizations, county and municipal entities, businesses, and local philanthropic organizations to assess the economic, health and community impact of substance abuse in Barnstable County IV. Identify key partners and evaluate existing education, prevention and intervention initiatives Expected Outcomes FY14-16: Community Benefits grants will support organizations that address substance abuse across the service area. Partnerships with key stakeholders will be developed to: Assess the impact of substance abuse on health and community systems Evaluate current substance abuse prevention and intervention efforts Develop comprehensive regional substance abuse prevention strategies Facilities and Resources: The hospitals and Community Benefits staff will play key roles in building county-wide collaborations to address issues of substance abuse. Resources allocated to these efforts will include staff, financial resources, and Community Benefits funding from both Cape Cod Hospital and Falmouth Hospital. Potential Collaborators: Barnstable County Human Services, Cape Cod Healthcare s Behavioral Health Services, Cape Cod Human Services, Falmouth Prevention Partnership, Freedom from Addiction Network, Gosnold on Cape Cod, and various municipal entities and relevant community organizations. 21

27 V. Seniors Priority: Support programs that address senior health challenges. Goal FY14-16: Respond to the diverse healthcare needs of a growing senior population including agerelated illnesses, disabilities, and increasing need for caregivers. Objectives FY14-16: Align existing initiatives and new programs to address the specific health needs of seniors Reduce the risk of hospitalization readmission for seniors Support community-based efforts to address senior health issues, including assisting in navigation of existing services and resources Support community initiatives to reduce the potential risks related to isolation that impact senior health Initiatives FY14-16: I. Support community-based programs that address senior health challenges, isolation and navigation of services through the annual Community Benefits grant program II. Support community-based programs that address issues that eliminate health disparities, promote wellness, and prevent/manage chronic disease for individuals who are elderly and/or persons with disabilities through FY14 Determination of Need grant funding facilitated by Community Health Network Area 27 (CHNA 27) III. Provide support to seniors with multiple medication regimens, complex conditions and/or at a high risk of falling or injury. Provide patient/family education, medication management, referral to appropriate community based services and care planning in coordination with the primary care provider IV. Strengthen strategic clinical and community affiliations to increase capacity to address agerelated diseases and healthcare needs Expected Outcomes FY14-16: Community Benefits grants will support programs that address senior health challenges and identify and connect isolated and at risk seniors to existing community resources. Clinical and community linkages will be strengthened to address the growing needs of age-related diseases and related care giving challenges. Hospital-based programs and initiatives will be expanded to meet the growing needs of seniors. The Visiting Nurse Association of Cape Cod, an affiliate organization of both hospitals, has been selected to launch an 18-month Navigator Pilot Project. This project is intended to improve access to information and the coordination of home-based long term services and support for residents of Cape Cod, including seniors. Hospitals will be able to leverage these services to increase care coordination and referrals to community-based services for seniors, including those with disabilities or complex conditions. Facilities and Resources: Resources from Cape Cod Hospital, Falmouth Hospital and the affiliate programs, services and agencies of Cape Cod Healthcare will be coordinated to support key initiatives related to meeting the growing needs of seniors. Staff support, financial resources, and Community Benefits funding will be contributed by Cape Cod Hospital and Falmouth Hospital. Potential collaborators: Barnstable County Human Services, Community Health Network Area 27, Cape Cod Foundation, COAST (Councils on Aging Serving Together), Elder Services of Cape Cod and the Islands, Reaching Elders with Additional Community Help (REACH) program of Cape & Islands Emergency Medical Services System, Visiting Nurse Association of Cape Cod, and other relevant community organizations. 22

28 VI. Youth and Young Adults Priority: Support community-based programs that encourage positive health and lifestyle choices among youth and young adults. Goal FY14-16: Support community-based efforts to improve health outcomes for youth and young adults, especially residents aged Objectives FY14-16: Support initiatives that address the health and at-risk behaviors of youth and young adults through the annual Community Benefits grants funding Support community-based education initiatives targeted at reducing the risk of injury, substance abuse, and sexually transmitted diseases among youth and young adults Initiatives FY14-16: I. Support community-based programs that address the health outcomes and at-risk behaviors of youth and young adults, ages 15 to 24, through the annual Community Benefits grant program II. Community Benefits staff will assist in developing strategic clinical-community linkages between staff across the healthcare system, including Cape Cod Hospital Emergency Room, Falmouth Hospital Emergency Room, Cape Cod Healthcare Infectious Disease Clinical Services, Cape Cod Healthcare Behavioral Health Services, and key organizations serving youth in Barnstable County Expected Outcomes FY14-16: Community Benefits grants will support programs that improve the health outcomes of youth and young adults including at-risk behaviors. Relationships between community organizations and clinical staff will be strengthened to provide connections to community-based services for young adults and their families. Youth will be identified as a specific vulnerable and at-risk population when addressing the broader issues of infectious disease and substance abuse. Clinical-community linkages will be developed to leverage key organizations working with youth and parents on education, prevention, and treatment strategies. Facilities and Resources: Both hospitals will play a supporting role to community-based education and health improvement efforts for youth and young adults across the service area. Staff, financial resources and Community Benefits funding from Cape Cod Hospital and Falmouth Hospital will be allocated to support communitybased efforts. Potential Collaborators: Barnstable County Human Services, Big Brothers Big Sisters of Cape Cod and the Islands, Cape Cod Community College, Cape Cod District Attorney s Office, Cape Cod Healthcare s Behavioral Health Services, Cape Cod Healthcare s Infectious Disease Clinical Services, Cape Cod Neighborhood Support Coalition, Cape & Islands Gay Straight Youth Alliance, County Network of Cape Cod, MA Department of Public Health, YMCA, Youth Suicide Prevention Project, and regional, town, or vocational school systems, and other relevant community organizations. 23

29 APPENDICES

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31 TABLE OF CONTENTS Appendix A: Appendix B: Appendix C: Appendix D: Appendix E: Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K: Glossary of Terms and Abbreviations List of Available Health Care Facilities, Services and Community Organizations Community Health Needs Assessment Methodology Barnstable County Demographics Data Chronic and Infectious Disease Data Access to Health Care Data Mental Health Data Substance Abuse Data Senior Health Data Youth and Young Adult Health Data Behavioral Risk Factors Surveillance System Report, , Barnstable County & Massachusetts; prepared by Barnstable County Human Services

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33 Appendix A: Glossary of Terms and Abbreviations Age-adjusted Rates: The age-adjusted rate is the crude rate adjusted for unequal age distributions across different year and geographic comparisons. Age-adjusted rates for each year and geographic area standardize the distribution of ages across all comparisons. The potential effect of an older or younger population is neutralized. Age-adjusted rates are standardized to the U.S Census Population unless noted otherwise and are generally reported in rates per 100,000 persons. Age-specific Rates: Similar to crude rates, it is the total number of cases divided by the total population of the specific age group. Confidence Intervals: An interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference. Confidence intervals are provided where and when available for only the most current comparisons between Barnstable County, Massachusetts and the United States. Confidence intervals at the 95% significance level are shown. Crude Rates: The total number of events divided by the total population and then multiplied by 1,000 or 100,000. Prevalence Rates: The number of cases for a given year divided by the population and then multiplied by 1,000 or 100,000. They are reported as a rate per 1,000 or 100,000 persons. Generally used when reporting disease statistics to help understand how much of the population is affected. Incidence Rates: The number of new cases for a given year divided by the population and then multiplied by 1,000 or 100,000. Generally used when reporting disease statistics to help understand the likelihood or vulnerability of new cases in a population. Mortality Rates: The number of deaths per unit, usually 1,000 or 100,000, of a population in a given place and time. MDPH: Massachusetts Department of Public Health ACS: American Community Survey MassCHIP: Massachusetts Community Health Information Profile BRFSS: Behavioral Risk Factor Surveillance System CDC: Centers for Disease Control and Prevention NCHS: National Center for Health Statistics CHNA: Community Health Needs Assessment N/A: Not available MA: Massachusetts U.S.: United States

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35 Appendix B: List of Available Health Care Facilities, Services and Community Organizations The following is a partial list of health care services, facilities and community organizations that provide services in Barnstable County related to the significant health needs identified through the Community Health Needs Assessment. Chronic and Infectious Disease Cape Cod Healthcare Services: Cape Cod Healthcare Cardiovascular Services Cape Cod Healthcare Diabetes Education Services Cape Cod Healthcare Infectious Disease Clinical Services Cape Cod Healthcare Neuroscience and Pain Cape Cod Healthcare Orthopedic Services Cape Cod Healthcare Radiology/Imaging Cape Cod Healthcare Regional Cancer Network Cape Cod Healthcare Rehabilitation Services Cape Cod Healthcare Wound Care Center Cape Cod Hospital C-Lab Clark Cancer Center Davenport-Mugar Cancer Center Falmouth Hospital JML Care Center Medical Affiliates of Cape Cod (MACC) Community Based Services: AIDS Support Group of Cape Cod American Cancer Society American Heart Association American Lung Association Barnstable County Public Health Nurse Cape & Islands Emergency Medical Services System Inc. Cape Cod Cooperative Extension Cape Cod Regional Tobacco Control Program Daybreak Alzheimer's Day Program in Eastham Falmouth Family Planning Health Imperatives-Hyannis Family Planning Hope Dementia and Alzheimer s Services of Cape Cod & the Islands Hope Health Lyme Awareness of Cape Cod MA Department of Public Health My Life, My Health: Cape Cod Coalition National Multiple Sclerosis Society Oral Health Excellence Collaborative Parkinson Support Network Sight Loss Services Visiting Nurses Association (VNA) of Cape Cod YMCA Diabetes Resource Center

36 Access to Healthcare Cape Cod Healthcare Services: Bourne Health Center Cape Cod Healthcare Family Birthplace Cape Cod Healthcare Interpreter Services Cape Cod Hospital Cape Cod Hospital Rehabilitation Center Cape Cod Hospital OB/GYN Clinic Cape Cod Hospital Pain Center Falmouth Hospital Falmouth Hospital Imaging at Community Health Center of Cape Cod Falmouth Hospital Outpatient Services Falmouth Hospital Outpatient Surgery Center Fontaine Medical Center Medical Affiliates of Cape Cod (MACC) Oppenheim Medical Building Primary Care Internists Rogers Outpatient Center Stoneman Outpatient Center Wilkens Medical Complex Community Based Services: A Baby Center Barnstable County Human Rights Commission Barnstable County Human Services Cape Cod Center for Women Cape Cod Council of Churches Cape Cod Immigrant Center Cape Cod Medical Reserve Corps Cape Cod WIC Cape Disability Network Community Action Committee of Cape Cod and Islands Community Health Center of Cape Cod Duffy Health Center Emerald Physicians Falmouth Human Services Falmouth Service Center Harbor Community Health Center - Hyannis Helping Our Women Lower Cape Outreach Council MA Department of Veterans Services Mashpee Wampanoag Health Service Unit Indian Health Services Outer Cape Health Services Parish Nurse Ministries of Cape Cod Specialty Network for the Uninsured The Family Pantry Town of Sandwich Public Health Nurse Department of Veterans Affairs Medical Center- Hyannis Veterans Outreach Center WE CAN

37 Mental Health: Cape Cod Healthcare Services: Cape Cod Healthcare Behavioral Health Services Cape Cod Hospital Cape Cod Hospital Psychiatric Center Cape Cod Human Services Falmouth Hospital Community Based Services: Allied Health Providers Baybridge Clubhouse Bayview Associates- South Shore Mental Health Cape and Islands Suicide Prevention Coalition Cape Cod Council of Churches Cape Cod Hoarding Task Force Cove Clubhouse Family Continuity Fellowship Health Services MA Department of Mental Health - Cape Cod Maternal Depression Task Force National Alliance on Mental Illness (NAMI) Resource Connection Center in Hyannis Samaritans on Cape Cod and the Islands South Bay Mental Health Vinfen Substance Abuse: Cape Cod Healthcare Services: Cape Cod Healthcare Behavioral Health Services Cape Cod Hospital Falmouth Hospital Community Based Services: CHAMP Homes Falmouth Prevention Partnership Freedom from Addiction Network Gosnold on Cape Cod Habit OPCO Senior Health: Cape Cod Healthcare Services: Cape Cod Hospital Falmouth Hospital Heritage at Falmouth JML Care Center Medical Affiliates of Cape Cod (MACC) Visiting Nurses Association (VNA) of Cape Cod

38 Community Based Services: Barnstable Council on Aging Bourne Council on Aging Brewster Council on Aging Bridging the Years- Supportive Day Program Cape Mediation - Elder Mediation Services Chatham Council on Aging COAST (COA's Serving Together) COMPASS VNA Adult Day Health Program Dennis Council on Aging Eastham Council on Aging Elder Services of Cape Cod and the Islands Falmouth Council on Aging Harwich Council on Aging Mashpee Council on Aging Orleans Council on Aging Provincetown Council on Aging REACH Program of CIEMSS Sandwich Council on Aging SHINE Trade Winds Adult Day Health Program Truro Council on Aging Wellfleet Council on Aging Yarmouth Council on Aging Youth and Young Adult Health: Cape Cod Healthcare Services: Cape Cod Hospital and Falmouth Hospital Cape Cod Human Services Medical Affiliates of Cape Cod (MACC) Community Based Services: Big Brothers Big Sisters of Cape Cod and the Islands Boys & Girls Club of Cape Cod Calmer Choice Cape Cod Child Development Cape Cod Community College Cape Cod District Attorney's Office Cape Cod Healthy Families Cape Cod Justice for Youth Cape Cod Neighborhood Support Coalition Cape Cod WIC Cape& Islands Gay Straight Youth Alliance Child and Family Services Children's Study Home County Network of Cape Cod Hyannis Youth and Community Center Kennedy Donovan Center Outer Cape WIC St. John's Episcopal Community Youth Project YMCA of Cape Cod Youth Suicide Prevention Project

39 Appendix C: Community Health Needs Assessment Methodology Activities and Timeline: I. Focus Groups and Community Input Forums (FY2012 and FY2013): The preliminary secondary data profile of Barnstable County and Cape Cod Healthcare s Community Benefits priorities were reviewed to determine focus group topic areas and craft questions for the focus group discussion guide. Based on this review, the areas that emerged as priorities for focus group research were youth, vulnerable populations, gaps and duplication in health and social services, access to healthcare barriers and emerging health needs. Participants were recruited to five focus groups held in January of 2012 based on their area of expertise concerning the topic and the population that they represented which included medically underserved, low-income, minority and vulnerable populations. In 2013, two Community Input Forums were hosted to present the identified significant community health needs, receive feedback from community leaders and health experts, and provide an opportunity for input on the prioritization of identified needs via a post-forum electronic survey. The event type, dates, location and topics discussed are listed below. Date Location Topic 01/18/12 Falmouth Hospital Focus Group Youth 01/18/12 Falmouth Hospital Focus Group Vulnerable Populations 01/18/12 Mashpee Health Center Focus Group Mental Health and Substance Abuse 01/19/12 Cape Cod Hospital Focus Group Youth 01/19/12 Cape Cod Hospital Focus Group Vulnerable Populations 06/26/13 Cape Cod Hospital Community Input Forum 06/27/13 Falmouth Hospital Community Input Forum Review and prioritization of significant health needs Review and prioritization of significant health needs II. Household Telephone Survey of Barnstable County Residents (FY2012) A total of 464 individuals who reside within Barnstable County were interviewed by telephone to assess their health practices and health status. Each interview lasted approximately minutes depending upon what criteria were met by the respondents. Only respondents who were at least 18 years of age and lived in a private residence were included. The survey instrument was adapted from the Center for Disease Control and Prevention s Behavioral Risk Factor Surveillance System (BRFSS).

40 III. Key Informant Interviews (FY2012 and FY2013) Key informant interviews were conducted with 20 individuals involved in non-profit organizations, public health, law enforcement, health care and social services. Participants were selected based on their area of expertise and knowledge concerning chronic and infectious disease, mental health, substance abuse, youth, seniors, and vulnerable populations. The community health needs assessment process and Community Benefits Priorities were reviewed with each key-informant. The discussion guide prepared for the focus groups was utilized as a basis for the interview in order to maintain uniformity in qualitative responses. Key informants were asked about their perceptions of issues which impact the health and well-being of the residents of Barnstable County. Interviews were conducted in FY2012 and FY2013 by staff of the Community Benefits department. IV. Secondary Data Profile (FY2012 FY2013) Statistics for the secondary data profile were gathered using the U.S. Census, state and local health departments, and other community resources. Statistics gathered included census figures, household statistics, education rates, mortality rates, maternal and child health indicators, disease incidence and prevalence rates, and hospital utilization data. Every effort was made to provide county-level data with comparisons to Massachusetts and the United States. V. Useful Websites For more demographics and other health data please see these useful websites:

41 Appendix D: Barnstable County Demographics Data D1) Population Breakdown by Age: 2000, 2010, Table 1 of 2; Census Bureau, 2000 & 2010 Census D2) Population Breakdown by Age: 2000, 2010, Table 2 of 2; Census Bureau, 2000 & 2010 Census D3) Barnstable County Birth Counts: ; MDPH: MassCHIP D4) Veteran Status: 2000, 2010; Census Bureau, 2000 & 2010 Census; Department of Veteran Affairs D5) Population Breakdown by Race: 2000, 2010; Census Bureau: 2000 & 2010 Census D6) Household Type: 2000, 2010, Table 1 of 2; Census Bureau: 2000 & 2010 Census D7) Household Type: 2000, 2010, Table 2 of 2; Census Bureau: 2000 & 2010 Census D8) Income: 2000, , Table 1 of 2; U.S. Census Bureau: 2000 Census & American Community Survey, Estimates D9) Income: 2000, , Table 2 of 2; U.S. Census Bureau: 2000 Census & American Community Survey, Estimates D10) Family Poverty Statistics: ; U.S. Census Bureau: American Community Survey, Estimates D11) Individual Poverty Statistics: 2000, ; U.S. Census Bureau: American Community Survey, Estimates

42 D1: Population Breakdown by Age: 2000, 2010 Table 1 of Barnstable County Appendix D: Barnstable County Demographics Data 2010 Barnstable County 2010 Massachusetts 2010 United States Total population 222, ,888 6,547, ,745,538 Median age (years) Under 5 years 4.8% 4.1% 5.6% 6.5% 5 to 9 years 5.8% 4.6% 5.9% 6.6% 10 to 14 years 6.4% 5.1% 6.2% 6.7% 15 to 19 years 5.3% 5.6% 7.1% 7.1% 20 to 24 years 3.5% 4.4% 7.3% 7.0% 25 to 34 years 9.7% 8.2% 12.9% 13.3% 35 to 44 years 15.3% 10.6% 13.6% 13.3% 45 to 54 years 14.8% 15.9% 15.5% 14.6% 55 to 59 years 6.1% 8.2% 6.6% 6.4% 60 to 64 years 5.4% 8.4% 5.7% 5.4% 65 to 74 years 11.9% 12.4% 6.9% 7.0% 75 to 84 years 8.3% 8.7% 4.6% 4.3% 85 years and over 2.9% 3.9% 2.2% 1.8% 18 years and over 79.6% 82.7% 78.3% 76.0% 65 years and over 23.1% 25.0% 13.8% 13.0% Data Source: U.S Census Bureau: 2000 and 2010 Census D2: Population Breakdown by Age: 2000, 2010 Table 2 of 2 Barnstable County % Change Total population 222, , % Median age (years) % Under 5 years 10,599 8, % 5 to 9 years 12,811 9, % 10 to 14 years 14,208 11, % 15 to 19 years 11,725 12, % 20 to 24 years 7,735 9, % 25 to 34 years 21,595 17, % 35 to 44 years 33,982 22, % 45 to 54 years 32,802 34, % 55 to 59 years 13,524 17, % 60 to 64 years 11,984 18, % 65 to 74 years 26,357 26, % 75 to 84 years 18,461 18, % 85 years and over 6,447 8, % 18 years and over 176, , % 65 years and over 51,265 53, % Data Source: U.S Census Bureau: 2000 and 2010 Census

43 D3: Barnstable County Birth Counts: Birth Counts Barnstable County 1,992 2,049 1,966 1,996 1,932 1,982 1,905 1,987 1,834 1,790 1,711 Data Source: MDPH: MassCHIP D4: Veteran Status: 2000, Barnstable County 2010 Barnstable County 2010 Massachusetts 2010 United States Civilian Population 18 years and over 176, ,639 5,128, ,564,071 Veterans 18.4% 14.4% 7.7% 10.4% Data Source: Census Bureau: 2000 & 2010 Census; Department of Veteran Affairs D5: Population Breakdown by Race: 2000, 2010 Race alone or in combination with one or more other races: 2000 Barnstable County 2010 Barnstable County 2010 Massachusetts 2010 United States Total population 222, ,888 6,547, ,745,538 White 95.6% 94.5% 82.5% 74.8% Black or African American 2.4% 2.8% 7.8% 13.6% American Indian and Alaska Native 1.0% 1.3% 0.8% 1.7% Asian 0.8% 1.4% 6.0% 5.6% Native Hawaiian and Other Pacific Islander 0.1% 0.1% 0.2% 0.4% Some Other Race 1.9% 2.3% 5.6% 7.0% Hispanic or Latino (includes all races) 1.3% 2.2% 9.6% 16.3% Data Source: U.S Census Bureau: 2000 and 2010 Census

44 D6: Household Type: 2000, 2010 Table 1 of Barnstable County 2010 Barnstable County 2010 United States 2010 Massachusetts Total households 94,822 95,755 2,547, ,716,292 Family households (families) 64.4% 61.3% 63.0% 66.4% With own children under 18 years 24.3% 20.2% 28.3% 29.8% Husband-wife family 52.2% 48.3% 46.3% 48.4% With own children under 18 years 17.8% 14.1% 19.7% 20.2% Male householder, no wife present 2.3% 3.4% 4.2% 5.0% With own children under 18 years 1.3% 1.5% 1.8% 2.4% Female householder, no husband present 9.4% 9.6% 12.5% 13.1% With own children under 18 years 5.3% 4.6% 6.8% 7.2% Nonfamily households 35.6% 38.7% 37.0% 33.6% Householder living alone 29.5% 31.8% 28.7% 26.7% Male 10.7% 12.0% 12.1% 11.9% 65 years and over 3.5% 4.2% 3.0% 2.7% Female 18.8% 19.8% 16.7% 14.8% 65 years and over 10.9% 11.7% 7.7% 6.7% Households with individuals under 18 years 26.1% 22.2% 30.8% 33.4% Households with individuals 65 years and over 36.7% 39.4% 25.6% 24.9% Average household size Average family size Data Source: U.S Census Bureau: 2000 and 2010 Census D7: Household Type: 2000, 2010 Table 2 of 2 Barnstable County % Change Total households 94,822 95, % Family households (families) 61,041 58, % With own children under 18 years 23,071 19, % Husband-wife family 49,457 46, % With own children under 18 years 16,833 13, % Male householder, no wife present 2,168 3, % With own children under 18 years 1,220 1, % Female householder, no husband present 8,939 9, % With own children under 18 years 5,000 4, % Nonfamily households 33,781 37, % Householder living alone 27,986 30, % Male 10,145 11, % 65 years and over 3,282 4, % Female 17,841 18, % 65 years and over 10,355 11, % Households with individuals under 18 years 24,780 21, % Households with individuals 65 years and over 34,803 37, % Average household size % Average family size %

45 Data Source: U.S Census Bureau: 2000 and 2010 Census D8: Income: 2000, Table 1 of Barnstable County Barnstable County United States Massachusetts Total households 94,845 96,775 2,522, ,761,359 Less than $10, % 5.1% 6.5% 7.1% $10,000 to $14, % 4.3% 5.1% 5.4% $15,000 to $24, % 9.0% 8.4% 10.6% $25,000 to $34, % 8.9% 7.8% 10.4% $35,000 to $49, % 14.0% 11.1% 13.8% $50,000 to $74, % 18.8% 16.5% 18.3% $75,000 to $99, % 14.4% 13.4% 12.4% $100,000 to $149, % 14.5% 16.6% 12.7% $150,000 to $199, % 5.9% 7.3% 4.7% $200,000 or more 2.4% 5.0% 7.2% 4.5% Median household income $45,933 $60,525 $65,981 $52,762 Mean household income N/A $80,076 $88,577 $72,555 With earnings 72.0% 70.9% 79.5% 79.2% Mean earnings $56,673 $76,304 $92,195 $73,702 With Social Security 39.0% 41.4% 27.5% 27.9% Mean Social Security income $12,169 $17,428 $15,836 $16,213 With retirement income 26.3% 26.3% 16.2% 17.5% Mean retirement income $18,771 $29,470 $23,351 $22,490 With Supplemental Security Income 3.7% 3.4% 5.1% 4.3% Mean Supplemental Security Income $6,726 $9,050 $9,072 $8,629 With cash public assistance income 1.8% 1.9% 2.8% 2.6% Mean cash public assistance income $3,930 $4,742 $4,734 $3,729 With Food Stamp/SNAP benefits in the past 12 months N/A 5.4% 9.5% 10.2% Data Source: U.S. Census Bureau: 2000 Census & American Community Survey, Estimates

46 D9: Income: 2000, Table 2 of 2 Barnstable County % Change Total households 94,845 96, % Less than $10,000 6,478 4, % $10,000 to $14,999 5,484 4, % $15,000 to $24,999 11,359 8, % $25,000 to $34,999 12,148 8, % $35,000 to $49,999 15,935 13, % $50,000 to $74,999 20,425 18, % $75,000 to $99,999 11,243 13, % $100,000 to $149,999 7,605 14, % $150,000 to $199,999 1,873 5, % $200,000 or more 2,295 4, % Median household income $45,933 $60, % Mean household income N/A $80,076 N/A With earnings 68,259 68, % Mean earnings $56,673 $76, % With Social Security 36,990 39, % Mean Social Security income $12,169 $17, % With retirement income 24,969 25, % Mean retirement income $18,771 $29, % With Supplemental Security Income 3,543 3, % Mean Supplemental Security Income $6,726 $9, % With cash public assistance income 1,672 1, % Mean cash public assistance income $3,930 $4, % With Food Stamp/SNAP benefits in the past 12 months N/A 5,237 N/A Data Source: U.S. Census Bureau: 2000 Census & American Community Survey, Estimates D10: Family Poverty Statistics: 2000, Barnstable Barnstable United Percentage of Families in Poverty County County Massachusetts States All families 4.6% 5.6% 7.6% 10.5% With related children under 18 years 8.1% 10.2% 11.8% 16.4% With related children under 5 years only 9.8% 9.2% 12.5% 17.7% Married couple families N/A 2.6% 2.9% 5.1% With related children under 18 years N/A 2.7% 3.4% 7.4% With related children under 5 years only N/A 2.9% 3.6% 6.6% Families with female householder, no husband present 17.4% 20.0% 24.5% 29.4% With related children under 18 years 25.5% 30.1% 33.5% 38.2% With related children under 5 years only 41.5% 35.9% 40.1% 46.3% Data Source: U.S. Census Bureau: American Community Survey, Estimates

47 D11: Individual Poverty Statistics: 2000, Barnstable Barnstable United Percentage of Individuals in Poverty County County Massachusetts States All people 6.9% 8.4% 10.7% 14.3% Under 18 years 6.3% 12.2% 13.5% 20.0% Related children under 18 years 8.6% 11.3% 13.2% 19.6% Related children under 5 years N/A 10.3% 15.5% 23.2% Related children 5 to 17 years 8.5% 11.5% 12.3% 18.3% 18 years and over N/A 7.6% 9.9% 12.5% 18 to 64 years N/A 8.2% 10.0% 13.1% 65 years and over 5.0% 6.1% 9.3% 9.4% People in families N/A 5.8% 7.8% 11.8% Unrelated individuals 15 years and over 15.0% 17.4% 21.9% 25.3% Data Source: U.S. Census Bureau: American Community Survey, Estimates

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49 Appendix E: Chronic and Infectious Disease E1) Top Fifteen National Causes of Death (Mortality Rate); MDPH: MassCHIP; CDC, NCHS: CDC Wonder Online Database E2) Cancer Mortality Rates Trended: ; MDPH: MassCHIP, CDC, CDC: National Program of Cancer Registries E3) Cancer Mortality Rates; MDPH: MassCHIP, CDC: National Program of Cancer Registries E4) Cancer Incidence Rates; MDPH: MassCHIP, CDC: National Program of Cancer Registries E5) Heart Disease Mortality Rates: ; MDPH: MassCHIP, CDC, NCHS: Division of Vital Statistics; CDC Wonder Database E6) Diabetes Mortality Rates; MDPH: MassCHIP, CDC, NCHS: Division of Vital Statistics; CDC Wonder Database E7) Barnstable County HIV/AIDS Incidence Counts: ; MDPH: MassCHIP; CDC: HIV/AIDS E8) Barnstable County HIV/AIDS Incidence Rates: ; Data Source: MDPH: MassCHIP; CDC: HIV/AIDS E9) HIV/AIDS Prevalence Rates; MDPH: MassCHIP E10) Barnstable County HIV/AIDS Prevalence Rates: ; MDPH: MassCHIP E11) Barnstable County HIV/AIDS Prevalence Counts: ; MDPH: MassCHIP E12) Communicable/Infectious Disease Incidence Rates; MDPH: MassCHIP E13) Barnstable County Communicable/Infectious Disease Incidence Rates Trended: , Table 1 of 2; MDPH: MassCHIP E14) Barnstable County Communicable/Infectious Disease Incidence Rates Trended: , Table 2 of 2; MDPH: MassCHIP E15) Sexually Transmitted Diseases Incidence Rates; MDPH: MassCHIP E16) Barnstable County Sexually Transmitted Diseases Incidence Rates Trended: ; MDPH: MassCHIP E17) New Cases of Sexually Transmitted Diseases in Barnstable County Trended: ; MDPH: MassCHIP

50 Appendix E: Chronic and Infectious Disease Data E1: Top Fifteen National Causes of Death (Mortality Rate) 2009 In order by Barnstable Deaths (Age-Adjusted Rates Per 100,000) Barnstable County 2009 Massachusetts 2009 United States Cancer ( ) ( ) ( ) Heart Disease ( ) ( ) ( ) Accidents (Unintentional injuries) (Crude) (Crude) 38.5 (Crude) ( ) ( ) ( ) Cerebrovascular Diseases ( ) ( ) ( ) Chronic Lower Respiratory Diseases ( ) ( ) 42.7 ( ) Alzheimer's Disease ( ) ( ) ( ) Nephritis, Nephrosis ( ) ( ) ( ) Suicide ( ) ( ) ( ) Chronic Liver Disease ( ) ( ) ( ) Diabetes Mellitus ( ) ( ) ( ) Pneumonia and Influenza ( ) ( ) ( ) Septicemia ( ) ( ) ( ) Parkinson's Disease ( ) ( ) ( ) Hypertension ( ) ( ) ( ) Homicide ( ) ( ) ( ) Note: Numbers listed under mortality rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP; CDC, NCHS: CDC Wonder Online Database

51 E2: Cancer Mortality Rates Trended: Age-Adjusted per 100, MA BCTY Data Source: MDPH: MassCHIP, CDC, CDC: National Program of Cancer Registries

52 E3: Cancer Mortality Rates Age-Adjusted Rates Per 100,000 people Cancer All Types Lung Breast (Female) Prostate Colorectal Pancreas Ovary Bladder Brain & Central Nervous System Leukemia Esophagus Lymphoma, Non Hodgkin Liver Uterine (Corpus Uteri) Melanoma/Skin Multiple Myeloma Stomach Soft Tissues Kidney Oral Cavity Cervical (Cervix Uteri) Mesothelioma Larynx (Continued on next page) 2009 Barnstable County ( ) ( ) ( ) ( ) ( ) ( ) ( ) 6.42 ( ) 6.36 ( ) 6.12 ( ) 5.91 ( ) 5.54 ( ) 4.75 ( ) 4.10 ( ) 3.62 ( ) 3.17 ( ) 2.97 ( ) 2.08 ( ) 2.04 ( ) 2.01 ( ) 0.87 ( ) 0.79 ( ) 0.75 ( ) 2009 Massachusetts ( ) ( ) ( ) ( ) ( ) ( ) 7.68 ( ) 5.25 ( ) 4.71 ( ) 6.51 ( ) 4.96 ( ) 5.37 ( ) 6.08 ( ) 4.29 ( ) 3.03 ( ) 3.61 ( ) 3.34 ( ) 1.48 ( ) 3.55 ( ) 2.20 ( ) 1.66 ( ) 0.89 ( ) 0.93 ( ) 2009 United States ( ) 48.5 ( ) 22.2 ( ) 22.0 ( ) 15.7 ( ) 10.8 ( ) 7.8 ( ) 4.3 ( ) 4.4 ( ) 7.0 ( ) 4.2 ( ) 6.3 ( ) 5.8 ( ) 4.2 ( ) 2.8 ( ) 3.3 ( ) 3.4 ( ) 1.3 ( ) 3.9 ( ) 2.4 ( ) 2.3 ( ) 0.8 ( ) 1.1 ( )

53 E3: Cancer Mortality Rates (continued) Age-Adjusted Rates Per 100,000 people 2009 Barnstable County 2009 Massachusetts 2009 United States Testis ( ) ( ) ( ) Thyroid ( ) ( ) ( ) Lymphoma, Hodgkin Disease ( ) ( ) ( ) Bone ( ) ( ) ( ) Note: Numbers listed under mortality rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP, CDC: National Program of Cancer Registries E4: Cancer Incidence Rates Rates per 100,000 people All Cancer Prostate Breast (female invasive) Breast (female non-invasive) Lung Colorectal (Invasive) Melanoma/Skin Uterine (Corpus Uteri) Bladder (invasive & noninvasive) Lymphoma, Non-Hodgkin Disease Leukemia Oral Cavity Kidney Ovary Thyroid Pancreas Brain & Central Nervous System Liver (Continued on next page) 2008 Barnstable County ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 6.86 ( ) 2008 Massachusetts ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 7.25 ( ) 7.62 ( ) 2008 United States ( ) ( ) N/A N/A 66.6 ( ) N/A 19.4 ( ) 24.7 ( ) 20.9 ( ) 19.3 ( ) 12.4 ( ) 11.2 ( ) 16.0 ( ) 12.4 ( ) 12.7 ( ) 12.1 ( ) 6.7 ( ) 6.8 ( )

54 E4: Cancer Incidence Rates (continued) Rates per 100,000 people 2008 Barnstable County 2008 Massachusetts 2008 United States Testis ( ) ( ) ( ) Colorectal (Non-invasive) ( ) ( ) N/A Cervical (Cervix Uteri) ( ) ( ) ( ) Stomach ( ) ( ) ( ) Multiple Myeloma ( ) ( ) ( ) Esophagus ( ) ( ) ( ) Larynx ( ) ( ) ( ) Lymphoma, Hodgkin Disease ( ) ( ) ( ) Soft Tissues ( ) ( ) ( ) Mesothelioma N/A ( ) ( ) Note: Cells with N/A indicate that the data is not available due to low counts and/or not enough data points Note: Numbers listed under incidence rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP, CDC: National Program of Cancer Registries E5: Heart Disease Mortality Rates: Age-Adjusted Rates per 100, MA BCTY Data Source: MDPH: MassCHIP, CDC, NCHS: Division of Vital Statistics; CDC Wonder Database

55 E6: Diabetes Mortality Rates Age-Adjusted Mortality Rates Per 100, Barnstable County 2009 Massachusetts 2009 United States Total ( ) ( ) ( ) Male ( ) ( ) ( ) Female ( ) ( ) ( ) Race White ( ) ( ) ( ) Black ( ) ( ) ( ) Hispanic ( ) ( ) ( ) Asian/Pacific Islander ( ) ( ) ( ) American Indian ( ) ( ) ( ) Age 0 to 9 yrs ( ) ( ) N/A 10 to 19 yrs ( ) ( ) N/A 20 to 24 yrs ( ) ( ) N/A 25 to 44 yrs ( ) ( ) N/A 45 to 64 yrs ( ) ( ) N/A 65 to 74 yrs ( ) ( ) N/A 75 years or more ( ) ( ) N/A Note: Numbers listed under mortality rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database

56 E7: Barnstable County HIV/AIDS Incidence Counts: HIV/AIDS Incidence Counts Barnstable County N/A Note: Cells with N/A indicate that the data is not available due to low counts and/or not enough data points Data Source: MDPH: MassCHIP; CDC: HIV/AIDS E8: Barnstable County HIV/AIDS Incidence Rates: Rates per 100, Barnstable County Data Source: MDPH: MassCHIP; CDC: HIV/AIDS E9: HIV/AIDS Prevalence Rates Rates per 100, Barnstable County 2009 Massachusetts HIV/AIDS Prevalence ( ) ( ) Note: Numbers listed under prevalence rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP

57 E10: Barnstable County HIV/AIDS Prevalence Rates: Rates per 100, Barnstable County Data Source: MDPH: MassCHIP E11: Barnstable County HIV/AIDS Prevalence Counts: HIV/AIDS Prevalence Counts Barnstable County Data Source: MDPH: MassCHIP

58 E12: Communicable/Infectious Disease Incidence Rates 2009 Barnstable Incidence Rates Per 100,000 County Lyme Disease ( ) Hepatitis C (Chronic) ( ) Salmonella ( ) Campylobacter ( ) Giardia 5.74 ( ) Animal Rabies* 4.86 ( ) Pertussis 3.97 ( ) Hepatitis B (Chronic) 3.09 ( ) Shigella Incidence* 2.21 ( ) 2009 Massachusetts ( ) ( ) ( ) ( ) ( ) 2.37 ( ) 5.76 ( ) ( ) 2.46 ( ) * 2008 Data Note: Numbers listed under incidence rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP

59 E13: Barnstable County Communicable/Infectious Disease Incidence Rates Trended: , Table 1 of Rates per 100, Lyme Disease Hepatitis C (Chronic) Salmonella Campylobacter Data Source: MDPH: MassCHIP E14: Barnstable County Communicable/Infectious Disease Incidence Rates Trended: , Table 2 of Rates per 100, Giardia N/A Pertussis Hepatits B (Chronic) N/A 3.1 Note: Cells with N/A indicate that the data is not available due to low counts and/or not enough data points Data Source: MDPH: MassCHIP

60 E15: Sexually Transmitted Diseases Incidence Rates Rates per 100, Barnstable County 2010 Massachusetts Chlamydia ( ) ( ) Gonorrhea ( ) ( ) Syphilis ( ) ( ) Note: Numbers listed under incidence rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP E16: Barnstable County Sexually Transmitted Diseases Incidence Rates Trended: Rates per 100, Chlamydia Gonorrhea Syphilis N/A Note: Cells with N/A indicate that the data is not available due to low counts and/or not enough data points Data Source: MDPH: MassCHIP E17: New Cases of Sexually Transmitted Diseases in Barnstable County Trended: New Cases Chlamydia Gonorrhea Syphilis N/A Data Source: MDPH: MassCHIP

61 Appendix F: Access to Health Care Data F1) Barnstable County, Massachusetts and United States Health Insurance Coverage; U.S. Census Bureau, American Community Survey, 2011 Estimates F2) Barnstable County Telephone Survey Question: About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. Barnstable County Household Telephone Survey, 2012

62 Appendix F: Access to Health Care Data F1: Barnstable County, Massachusetts and United States Health Insurance Coverage 2011 Barnstable County 2011 Massachusett s 2011 United States Civilian Non-institutionalized Population 212,896 6,507, ,560,685 With health insurance coverage 92.7% 95.7% 84.9% With private health insurance coverage 72.2% 75.0% 65.2% With public health coverage 43.0% 32.8% 30.5% No health insurance coverage 7.3% 4.3% 15.1% Civilian Non-institutionalized Population Under 18 years 35,973 1,401,873 73,774,529 No health insurance coverage 5.3% 1.7% 7.5% Data Source: U.S. Census Bureau, American Community Survey, 2011 Estimates F2: Barnstable County Telephone Survey Question: About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition. 90.0% 86.1% 84.5% 80.0% 73.2% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 11.8% 7.1% 9.4% Within past year Within past 2 years 4.5% 7.0% 7.1% 3.5% 2.3% 2.2% 0.0% 0.3% Within past 5 years 5 or more years ago Never 1.0% Barnstable County Massachusetts United States Data Source: Barnstable County Household Telephone Survey, 2012

63 Appendix G: Mental Health Data G1) Barnstable County Telephone Survey Question: Has a doctor or other healthcare provider ever told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)? Barnstable County Household Telephone Survey, 2012 G2) Suicide Deaths; MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database G3) Barnstable County Suicide Rates Trended: ; MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database G4) Barnstable County Suicide Counts Trended: ; MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database

64 Appendix G: Mental Health Data G1: Barnstable County Telephone Survey Question: Has a doctor or other healthcare provider ever told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)? 84.4% 86.7% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 15.6% Yes 13.3% Barnstable County No United States Data Source: Barnstable County Household Telephone Survey, 2012 G2: Suicide Deaths 2009 Barnstable County 2009 Massachusetts 2009 United States Count , Crude Rate Per 100, ( ) ( ) Age-Adjusted Rate 100, ( ) ( ) Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database

65 G3: Barnstable County Suicide Rates Trended: Age Adjusted Rates per 100, BCTY Data Source: MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database G4: Barnstable County Suicide Counts Trended: Count Barnstable County Data Source: MDPH: MassCHIP; CDC, NCHS: Division of Vital Statistics; CDC Wonder Database

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67 Appendix H: Substance Abuse Data H1) Substance Abuse Admissions to MDPH Funded Treatment Programs; MDPH: MassCHIP H2) Barnstable County Substance Abuse Admission Rates to MDPH Funded Treatment Programs Trended: ; MDPH: MassCHIP H3) Barnstable County Substance Abuse Admission Counts to MDPH Funded Treatment Programs Trended: ; MDPH: MassCHIP H4) Barnstable County Substance Abuse Admission Rates to MDPH Funded Treatment Programs: Admission Types Trended: ; MDPH: MassCHIP H5) Barnstable County Substance Abuse Admission Counts to MDPH Funded Treatment Programs: Admission Types Trended: ; MDPH: MassCHIP H6) Enrollment Summary: Primary Substance of Use; Bureau of Substance Abuse Service, MDPH

68 Appendix H: Substance Abuse Data H1: Substance Abuse Admissions to MDPH Funded Treatment Programs 2010 Barnstable County 2010 Massachusetts Total Substance Abuse Admissions 2, (2, ,343.12) 1, (1, ,599.44) Alcohol was primary substance 1, (1, ,174.65) ( ) Heroin was primary substance ( ) ( ) Other primary substance ( ) ( ) Cocaine was primary substance ( ) ( ) Crack was primary substance ( ) ( ) Marijuana was primary substance ( ) ( ) Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP H2: Barnstable County Substance Abuse Admission Rates to MDPH Funded Treatment Programs Trended: ,350 2,300 2,250 Rates Per 100,000 2,200 2,150 2,100 2,050 2,000 1,950 1, Barnstable County Data Source: MDPH: MassCHIP

69 H3: Barnstable County Substance Abuse Admission Counts to MDPH Funded Treatment Programs Trended: Counts Barnstable County 4,831 4,989 5,200 5,039 4,786 4,698 4,802 4,921 4,662 4,953 5,168 Data Source: MDPH: MassCHIP H4: Barnstable County Substance Abuse Admission Rates to MDPH Funded Treatment Programs: Admission Types Trended: Rates Per 100, Data Source: MDPH: MassCHIP Alcohol Heroin Other Substance Cocaine Crack Marijuana

70 H5: Barnstable County Substance Abuse Admission Counts to MDPH Funded Treatment Programs: Admissions Types Trended: Counts Alcohol 3,090 2,992 3,116 3,000 2,715 2,600 2,643 2,743 2,503 2,620 2,562 Heroin 934 1,104 1, , Other substance Cocaine Crack Marijuana Data Source: MDPH: MassCHIP H6: Enrollment Summary: Primary Substance of Use Enrollment Summary Barnstable County ( ) Enrollment Summary Massachusetts ( ) Alcohol was primary substance 51.28% 39.07% Heroin was primary substance 19.26% 38.04% Other Opiates 17.93% 8.05% Crack/Cocaine was primary substance 4.95% 6.40% Marijuana was primary substance 4.42% 5.76% Other Substance 1.66% 1.65% Data Source: Bureau of Substance Abuse Service, MDPH

71 Appendix I: Senior Health Data I1) Barnstable County Telephone Survey Question: In the past three months, how many times have you fallen? Barnstable County Household Telephone Survey, 2012 I2) Count of Deaths due to Alzheimer s disease Over Time: ; MDPH: MassCHIP I3) Barnstable County Telephone Survey Question: During the past month, did you provide any such care or assistance to a friend or family member? Barnstable County Household Telephone Survey, 2012 I4) Barnstable County Telephone Survey Question: Please indicate which one of the following is the greatest difficulty you have faced as a caregiver. Barnstable County Household Telephone Survey, 2012

72 Appendix I: Senior Health Data I1: Barnstable County Telephone Survey Question: In the past three months, how many times have you fallen? (Note: Only asked of respondents 45 years of age or older) 90% 86.5% 84.8% 83.3% 80% 70% 60% 50% 40% 30% 20% 13.3% 14.7% 16.1% 10% 0% 0.3% 0.5% 0.6% 0.0% 0.0% More than 10 6 to 10 1 to 5 None 0.0% Barnstable County Massachusetts United States Data Source: Barnstable County Household Telephone Survey, 2012 I2: Count of Deaths due to Alzheimer s disease Over Time: Barnstable County Data Source: MDPH: MassCHIP

73 I3: Barnstable County Telephone Survey Question: During the past month, did you provide any such care or assistance to a friend or family member? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 28.5% Yes 18.3% Barnstable County 71.5% No Massachusetts 81.7% Data Source: Barnstable County Household Telephone Survey, 2012 I4: Barnstable County Telephone Survey Question: Please indicate which one of the following is the greatest difficulty you have faced as a caregiver. 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 38.2% 23.5% 9.0% 8.8% 7.4% 4.2% 4.4% 3.7% 2.6% 3.2% 45.2% 23.2% 8.6% 1.2% 1.6% 3.8% 3.8% 5.0% Barnstable County United States Data Source: Barnstable County Household Telephone Survey, 2012

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75 Appendix J: Youth and Young Adult Health (Ages 15 24) Data J1) Adolescent (Ages 15 19) Motor Vehicle Accident Related Hospitalization by Gender; MDPH: MassCHIP J2) Young Adults (Ages 20 24) Motor Vehicle Accident Related Hospitalization by Gender; MDPH: MassCHIP J3) Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded); MDPH: MassCHIP J4) Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded) Trended: ; MDPH: MassCHIP J5) Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded): Admission Types Trended: ; MDPH: MassCHIP J6) Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded) Count: ; MDPH: MassCHIP J7) Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded); MDPH: MassCHIP J8) Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded) Trended: ; MDPH: MassCHIP J9) Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded): Admission Types Trended: ; MDPH: MassCHIP J10) Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded) Count: ; MDPH: MassCHIP J11) Adolescent (Ages 15 19) Sexually Transmitted Disease Rates; MDPH; MassCHIP J12) Barnstable County Adolescent (Ages 15 19) Sexually Transmitted Disease Rates Trended: ; MDPH: MassCHIP J13) Barnstable County Adolescent (Ages 15-19) Sexually Transmitted Diseases; New Cases Trended: ; MDPH: MassCHIP J14) Young Adult (Ages 20 24) Sexually Transmitted Disease Rates; MDPH: MassCHIP J15) Barnstable County Young Adult (Ages 20 24) Sexually Transmitted Disease Rates Trended: ; MDPH: MassCHIP J16) Barnstable County Young Adult (Ages 20 24) Sexually Transmitted Diseases; New Cases Trended: ; MDPH: MassCHIP

76 Appendix J: Youth and Young Adult Health (Ages 15 24) Data J1: Adolescent (Ages 15 19) Motor Vehicle Accident Related Hospitalization by Gender Adolescents, Ages Age Specific Rates Per 100, Barnstable County 2009 Massachusetts Motor Vehicle Related - Hospitalizations ( ) ( ) Male ( ) ( ) Female ( ) ( ) Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP J2: Young Adults (Ages 20 24) Motor Vehicle Accident Related Hospitalization by Gender Young Adults, Ages Age Specific Rates Per 100, Barnstable County* 2009 Massachusetts Motor Vehicle Related - Hospitalizations ( ) ( ) Male ( ) ( ) Female ( ) ( ) * These hospitalization rates are for all Barnstable County residents and not the hospitalization rates for Cape Cod Healthcare. Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP

77 J3: Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded) Adolescents, Ages Age Specific Rates Per 100, Barnstable County 2010 Massachusetts Substance Abuse Admissions 3, , (3, ,842.25) (1, ) Other was primary substance ( ) ( ) Alcohol was primary substance ( ) ( ) Heroin was primary substance ( ) ( ) Cocaine was primary substance* N/A ( ) Crack was primary substance* N/A 8.63 ( ) Marijuana was primary substance* ( ) ( ) *There were not enough data points and/or too low of a count to report rates Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP J4: Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded) Trended: Age Specific Rates per 100, Substance Abuse Admissions Data Source: MDPH: MassCHIP

78 J5: Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded): Admission Types Trended: Age Specific Rates per 100, Other Alcohol Heroin Marijuana Cocaine N/A N/A N/A N/A Note: Cells with N/A indicate that the data is not available due to low counts Data Source: MDPH: MassCHIP J6: Barnstable County Adolescent (Ages 15 19) Substance Abuse Treatment Admissions (MDPH Funded) Count: Counts All Admissions Other N/A Alcohol Heroin Marijuana Cocaine N/A N/A N/A N/A Crack N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Note: Cells with N/A indicate that there were not enough data points and/or too low of a count to report. Data Source: MDPH: MassCHIP

79 J7: Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded) Young Adult, Ages Age Specific Rates Per 100, Barnstable County 2010 Massachusetts Substance Abuse Admissions 9, (8, ,733.27) 4, (3, ,065.06) Heroin was primary substance 2, , (2, ,859.64) (1, ,018.07) Alcohol was primary substance 2, (1, ,362.97) ( ) Cocaine was primary substance ( ) ( ) Other was primary substance ( ) ( ) Crack was primary substance* N/A ( ) Marijuana was primary N/A substance* ( ) *There were not enough data points to report rates Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP J8: Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded) Trended: Age Specific Rates per 100, Substance Abuse Admissions Data Source: MDPH: MassCHIP

80 J9: Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded): Admission Types Trended: Age Specific Rates per 100, Heroin Alcohol Cocaine Other N/A Marijuana N/A 0.0 Note: Cells with N/A indicate that the data is not available due to low counts Data Source: MDPH: MassCHIP J10: Barnstable County Young Adult (Ages 20 24) Substance Abuse Treatment Admissions (MDPH Funded) Count: Counts All Admissions ,039 Heroin Alcohol Cocaine Other N/A Marijuana N/A N/A Crack N/A N/A N/A N/A N/A N/A N/A Note: Cells with N/A indicate that there were not enough data points and/or too low of a count to report. Data Source: MDPH: MassCHIP

81 J11: Adolescent (Ages 15 19) Sexually Transmitted Disease Rates Age-Specific Incidence Rates Per 100,000 Barnstable County Massachusetts Chlamydia , ( ) (1, ,343.69) Gonorrhea* ( ) ( ) Syphilis* ( ) ( ) *2009 data is reported because 2010 data had too few counts to report figures. Syphilis incidence rates for Barnstable County adolescents are all but nonexistent. Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP J12: Barnstable County Adolescent (Ages 15 19) Sexually Transmitted Disease Rates Trended: Age Specific Rates per 100, Chlamydia Gonorrhea N/A N/A Note: There were not enough counts for Syphilis to appear on the graph Data Source: MDPH: MassCHIP

82 J13: Barnstable County Adolescent (Ages 15 19) Sexually Transmitted Diseases; New Cases Trended: New Cases Chlamydia Gonorrhea N/A N/A Syphilis N/A *There were not enough data points and/or too low of a count to report new cases of Syphilis. Syphilis cases for Barnstable County adolescents are all but nonexistent. Data Source: MDPH: MassCHIP J14: Young Adult (Ages 20 24) Sexually Transmitted Disease Rates, 2010 Age Specific Incidence Rates Per 100, Barnstable County 2010 Massachusetts Chlamydia 1, , (1, ( ,338.27) ) Gonorrhea Syphilis* ( ) N/A ( ) ( ) *There were not enough data points to report incidence rates. Syphilis incidence rates for Barnstable County young adults are all but nonexistent. Note: Numbers listed under rates in bold reflect the confidence interval range. A confidence interval is an interval of values related to a measurement that indicates how precise the measurement is. It is used to indicate the reliability of an estimate and as a comparison tool to evaluate one finding against another. When comparing results, if the confidence intervals overlap there is no statistically significant difference, however, if they do not overlap than there is a statistically significant difference. Data Source: MDPH: MassCHIP

83 J15: Barnstable County Young Adult (Ages 20 24) Sexually Transmitted Disease Rates Trended: Age Specific Rates per 100, Chlamydia Gonorrhea Note: There were not enough counts for Syphilis to appear on the graph Data Source: MDPH: MassCHIP J16: Barnstable County Young Adult (Ages 20 24) Sexually Transmitted Diseases; New Cases Trended: New Cases Chlamydia Gonorrhea Syphilis* N/A N/A N/A *There were not enough data points and/or too low of a count to report new cases of Syphilis. Syphilis cases for Barnstable County young adults are all but nonexistent. Data Source: MDPH: MassCHIP

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85 Behavioral Risk Factor Surveillance System 2008 to 2010 Barnstable County and Massachusetts Prepared by Christine Clements Stein, MPH, PhD Rasneet Sandhu Barnstable County Department of Human Services August 10, 2012