Collier County Florida Health Assessment

Transcription

1 2013 Florida Health Assessment Prepared by: The Health Planning Council of Southwest Florida, Inc.

2 Table of Contents Introduction... 4 Demographic and Socioeconomic Characteristics... 5 Population Demographics... 5 Population Growth... 6 Age... 7 Gender... 7 Race and Ethnicity... 8 Socioeconomic Indicators... 9 Health Status Health Ranking Healthy People 2020 Objectives Death Rate Death Rates by Race Leading Causes of Death Deaths from All Causes Chronic Diseases Cancer Heart Disease Diabetes Communicable Diseases Sexually Transmitted Diseases Vaccine Preventable Diseases AIDS and Other Diseases Maternal and Child Health Mothers Who Smoked During Pregnancy Teen Births Infant Deaths Senior Citizen Health Alzheimer s Disease Oral Health Accessibility for Low-Income Residents Dental Emergencies Social and Mental Health

3 Crime and Domestic Violence Alcohol-related Motor Vehicle Crashes Florida Youth Substance Abuse Survey Suicides Baker Act Hospitalizations Emergency Room Visits Health Resources Medicaid Florida KidCare Uninsured Physicians and Facilities Federal Health Professional Shortage Designations Community Input Survey on Health and Healthcare Interviews with Community Leaders Appendices: Appendix A: HcN Community Health Assessment Group Members Appendix B: County Health Rankings Appendix C: Behavioral Risk Factor Surveillance Survey Appendix D: Survey on Health and Healthcare Appendix E: Survey on Health and Healthcare: Additional Comments Appendix F: Key Informant Interview Guide Appendix G: Community Leaders Interviewed Appendix H: Definitions of Prevention Quality Indicators Appendix I: Florida Youth Substance Abuse Survey Appendix J: Guide to Emergency and Health Services Appendix K: Selected Data Sources

4 Introduction In an effort to improve the health of the residents of, a collaborative partnership was formed between the Healthcare Network of Southwest Florida and the Health Planning Council of Southwest Florida, Inc. (HPC) for the purpose of conducting a needs assessment for use by the Healthcare Network of Southwest Florida and other community partners. The Healthcare Network of Southwest Florida created a community committee comprised of area residents and business leaders who showed an interest in improving the health of their community. A list of participating members of the HcN Community Health Assessment Group is available in Appendix A. This group held monthly meetings for the duration of the project to aid in the creation and implementation of this needs assessment. HPC reviewed numerous data sources and received feedback from the HcN Community Health Assessment Group as well as from members of the community through surveys and interviews. The assessment group reviewed the preliminary data that was collected, and provided feedback to the Health Planning Council. This needs assessment consists of demographic, socioeconomic and health status information that will be used to identify areas where targeted interventions and policy changes may have the greatest impact. Once community needs are identified through quantitative data analysis of demographic, socioeconomic and health status information, and qualitative interviews, the strategic planning process can begin. 4

5 Demographic and Socioeconomic Characteristics The demographic, social and economic characteristics of a community can strongly influence the community s health status and related service needs. These indicators should be a primary consideration when designing and developing any system of care within the region. This section provides a brief overview of some of the characteristics and trends that make unique in comparison to the state of Florida. Population Demographics The sheer number of people in a community is the leading determinant of the demand for healthcare services., which has a population of just over 327,000, is located in southwest Florida (Fig. 1). The county also shares borders with the following counties: Hendry to the north; Broward to the east; Miami-Dade to the southeast; Monroe to the south; and Lee to the northwest. As seen in Figure 2, Collier is one of seven counties in southwest Florida that comprise the Local Health Planning District 8 as designated by the Florida Agency for Health Care Administration (AHCA). Naples is the county seat and largest city. is 2, square miles in area; about 12 percent of that area is covered by water. It is the second largest county in the state of Florida, after Palm Beach County. According to the 2010 census figures, the county has a population density of about 161 persons per square mile compared to a state average of 351 persons per square mile. Figure 1: Figure 2: 5

6 Population Growth The illustration below represents the total population of from The estimate for 2012 places the population of at 327,058. This represents a 57 percent increase since Chart 1: Total Population Source: The Florida Legislature, Office of Economic and Demographic Research Population growth in a community is the result of natural increase (more births than deaths) and also the migration of people moving into the area at a higher rate than those who are leaving. According to the Office of Economic and Demographic Research, the population of is expected to continue to grow in the coming years. In 2016, it is estimated that the population of will be 350,757; that is an increase of seven percent from the same number for Chart 2: Estimated Population Source: The Florida Legislature, Office of Economic and Demographic Research 6

7 Age The largest proportion of the population of the county is between the ages of 45 and 64 which is the same for the state. However, has a larger elder population, aged 65 and older, than the state as a whole (26.9% Collier vs. 18.0% State). The median age in is higher than the state (46.9 Collier vs State). Chart 3: Population Percentage by Age Group Collier and State, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research Gender There are more women than men in. This is not surprising since women make up a larger proportion of the United States population as a whole and tend to live longer than men. In fact, a study based on 2009 data shows women have the highest life expectancy in the nation, living an average of 85.8 years percent of the residents of are female while 49.3 percent are male; statewide the percentages are 51.1 percent female and 48.9 percent male. Chart 4: Collier Population by Sex Percent of Total Population, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research 7

8 Race and Ethnicity 9.8 percent of the population of is non-white; compared to a statewide population comprised of 21.6 percent non-whites. Approximately 2.9 percent of the population is listed as Other non-white. This category includes American Indian, Alaskan Native, Asian, Native Hawaiian, and other Pacific Islanders, and those of mixed race who chose not to select white or black. Chart 5: Collier Population by Race Percent of Total Population, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research Ethnicity in Florida is broken out separately from race. For ethnicity, a person must designate themselves as Hispanic or Non-Hispanic; people in both of those groups can identify as white, black or other non-white. About 27 percent of the residents of identify as Hispanic; this is slightly higher than the state average. The vast majority of the people in who identify as Hispanic identify as white. Table 1: Race and Ethnicity, 2012 Collier State Hispanic Non-Hispanic Hispanic Non-Hispanic White 25.4% 64.8% White 21.2% 57.1% Black 0.6% 6.3% Black 1.2% 15.4% Other 0.8% 2.1% Other 0.8% 4.3% Total 26.8% 73.2% Total 23.2% 76.8% Source: The Florida Legislature, Office of Economic and Demographic Research 8

9 Socioeconomic Indicators The figures shown below summarize some of the primary indicators of economic health for the county and state. Like the rest of Florida, was affected by the economic downturn. The unemployment rate jumped from 3.7 percent in 2000 to 8.4 percent in 2012; it is slightly lower than the state rate of 8.7 percent. However, while the bankruptcy filing rate of the residents of rose between 2000 and 2011, that rate is still significantly lower than the state. The percent of people living under the poverty level in is lower than the state as a whole. Unfortunately, the percent of children 0-17 years of age who are under the poverty level is higher in ; that rate is 30.7 percent for compared to 25.1 percent for the state. Table 2: Socioeconomic Indicators and State County 2000 County 2011 State 2011 Labor Force as a % of Pop. Aged 18+ (2012*) 57.6% 57.4% 62.0% Personal Bankruptcy Filing Rate per 1, Unemployment Rate (2012*) 3.7% 8.4% 8.7% Average Annual Wage $40,975 $41,570 Per Capita Personal Income $39,965 $59,264 $39,636 % Living Below Poverty Level 16.2% 17.0% % ages 0-17 living below Poverty 30.7% 25.1% Source: The Florida Legislature, Office of Economic and Demographic Research *preliminary Slightly more residents of who are aged 25 and older have received a high school diploma than the state average. A larger percentage of people in have received a Bachelor s degree than the percentage of residents of Florida who have done the same. Table 3: Educational Attainment Persons aged 25 and older, Collier and State, 2011 Collier State % High School graduate or higher 86.4% 85.9% % Bachelor's degree or higher 32.2% 25.8% Source: The Florida Legislature, Office of Economic and Demographic Research 9

10 As seen in Chart 6, among working adults in the most common sectors of employment are: education and health services, leisure and hospitality, professional and business services, and retail trade. Chart 6: Average Employment by Category Collier and State, 2011 Source: Florida Legislature, Office of Economic and Demographic Research 10

11 Health Status Health Ranking County Health Rankings & Roadmaps, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, has currently ranked the 3 rd healthiest out of 67 counties in Florida for Health Outcomes, and 10 th healthiest for Health Factors. These rankings are based on a variety of factors that affect the health of the county s residents such as unemployment, levels of physical inactivity, and rates of smoking, obesity, and children living in poverty. The Health Outcomes portion of the rankings includes data on mortality and morbidity. was ranked the healthiest of all of the Florida counties for mortality, which is based on the years of potential life lost before the age of 75. Morbidity includes overall quality of health (poor or fair health, poor physical health days, and poor mental health days) as well as the percent of live births with low birth weight. In this category, ranked 4 th healthiest of all of the Florida counties. The Health Factors portion of the rankings includes data on health behaviors, clinical care, social & economic factors, and physical environment. was ranked as the 5 th healthiest county in Florida for health behaviors, which includes rates of adult smoking, adult obesity, physical inactivity, excessive drinking, motor vehicle crash deaths, sexually transmitted infections, and teen births. The teen birth rate in (48 per 1,000 female population, ages 15-19) is higher than that of the state (40) and considerably higher than the national benchmark (21). For clinical care, was ranked as the 17 th healthiest county. Clinical care includes data on the number of uninsured, primary care physicians, dentists, preventable hospital stays, diabetic screening, and mammography screening. The percent of population under age 65 without health insurance in (30%) was higher than that of the state average (25%) and considerably higher than the national benchmark (11%). Social & economic factors, where ranked 30 th healthiest out of 67 counties in Florida, includes rates of high school graduation, some college, unemployment, children in poverty, inadequate social support, children in single-parent households, and violent crime. In, the percent of the population age 16 and older who are unemployed but seeking work was 10.3 percent. This rate is slightly lower than that of the state (10.5%), but more than double the national benchmark (5.0%). The percent of children under age 18 in poverty was 31 percent, which is higher than the state average (25%) and significantly higher than the national benchmark (14%). Physical environment includes rates of daily fine particulate matter, drinking water safety, access to recreational facilities, limited access to healthy foods, and fast food restaurants. In this category, Collier County ranked 5 th healthiest. The percent of the population who are low-income and do not live close to a grocery store (limited access to healthy foods) (8%) was higher than the state average (7%) and significantly higher than the national benchmark (1%). A detailed breakdown of the ranking and full definitions for each health measure are available in Appendix B. 11

12 Healthy People 2020 Objectives Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. Healthy People 2020 is managed by the Office of Disease Prevention and Health Promotion within the US Department of Health and Human Services. Below is s data with relation to selected objectives (comparing 2007 Behavioral Risk Factor Surveillance Survey data with 2010 data, available in Appendix C). Mission Healthy People 2020 strives to: Identify nationwide health improvement priorities. Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. Provide measurable objectives and goals that are applicable at the national, State, & local levels. Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge. Identify critical research, evaluation, and data collection needs. Overarching Goals Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. Table 4: Healthy People 2020 Objectives 2010 Objective Measure Progress C-15. Increases the proportion of women who receive a cervical cancer screening based on the most recent guidelines. C-16. Increase the proportion of adults who receive a colorectal cancer screening based on the most recent guidelines. C-17. Increase the proportion of women who receive a breast cancer screening based on the most recent guidelines. D-9. Increase the proportion of adults with diabetes who have at least an annual foot examination. Percentage of women 18 years of age and older who received a Pap test in the past year. Percentage of adults 50 years of age and older who received a sigmoidoscopy or colonoscopy in the past five years. Percentage of women 40 years of age and older who received a mammogram in the past year. Percentage of women 18 years of age and older who had a clinical breast exam in the past year. Percentage of adults with diabetes who had an annual foot exam % 54.10% 61.00% 56.30% 64.70% 69.30% 64.40% 64.80% 63.10% 57.50% Needs Improvement Needs Improvement Progress Shown Needs Improvement Needs Improvement

13 D-10. Increase the proportion of adults with diabetes who have an annual dilated eye examination. D-11. Increase the proportion of adults with diabetes who have a glycosylated hemoglobin (A1C) measurement at least twice a year. D-13. Increase the proportion of adults with diabetes who perform self-blood glucose-monitoring at least once daily. D-14. Increase the proportion of persons with diagnosed diabetes who receive formal diabetes education. HDS-5. Reduce the proportion of persons in the population with hypertension. HIV-14. Increase the proportion of adolescents and adults who have been tested for HIV in the past 12 months. IID Increase the percentage of noninstitutionalized adults aged 65 years and older who are vaccinated against seasonal influenza. IID-13. Increase the percentage of adults who are vaccinated against pneumococcal disease. IID Increase the percentage of noninstitutionalized adults aged 65 years and older who are vaccinated against pneumococcal disease. NWS-8. Increase the proportion of adults who are at a healthy weight. NWS-9. Reduce the proportion of adults who are obese. SA-14. Reduce the proportion of persons engaging in binge drinking of alcoholic beverages. TU-4. Increase smoking cessation attempts by adult smokers. Percentage of adults with diabetes who had an annual eye exam. Percentage of adults with diabetes who had two A1C tests in the past year. Percentage of adults with diabetes who self-monitor blood glucose at least once a day on average. Percentage of adults with diabetes who ever had diabetes self-management education. Percentage of adults with diagnosed hypertension. Percentage of adults less than 65 years of age who have ever been tested for HIV. Percentage of adults age 65 and over who received a flu shot in the past year. Percentage of adults who have ever received a pneumonia vaccination. Percentage of adults age 65 and over who have ever received a pneumonia vaccination. Percentage of adults who have a healthy weight (BMI from 18.5 to 24.9) % 62.40% 54.40% 71.00% 73.70% 60.90% 75.00% 58.20% 29.80% 30.90% 38.20% 34.00% 74.80% 74.80% 35.20% 41.60% 71.90% 80.70% 38.30% 39.30% Percentage of adults who are obese % 22.40% Percentage of adults who engage in heavy or binge drinking. Percentage of adult current smokers who tried to quit smoking at least once in the past year % 19.20% 43.00% 49.80% Source: U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People Washington, DC. Available at Accessed February 27, Data source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. Needs Improvement Progress Shown Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Progress Shown Progress Shown Progress Shown Needs Improvement Needs Improvement Progress Shown 13

14 Death Rate The death rate for residents has been consistently lower than the state average. For the three-year period from , s death rate was twenty-five percent lower than the state s rate (507.5 per 100,000 vs State). The death rate for has been on the decline for the past twenty years, and has leveled off since Chart 7: Collier Death Rate over 20 Years Compared to State Age-Adjusted All Causes 3-Year Death Rate Source: Florida Department of Health, Office of Vital Statistics Age-adjusted death rates are computed using the year 2000 standard population. Death Rates by Race The overall death rate for blacks in is higher than that of whites (505.9 white population vs black population); this is also true for the state of Florida as a whole. From , the black population in had considerably higher rates of death due to heart disease, stroke, motor vehicle crashes, and diabetes than the white population. The black population in had diabetes death rates nearly four times as high as the white population (8.8 white population vs black population). The white population had considerably higher rates of death due to Alzheimer s disease than the black population (23.3 white population vs black population). The white population had nearly double the rates for suicide (12.8 white population vs. 7.7 black population) and cirrhosis (12.3 white population vs. 7.0 black population). Cancer and heart disease were the leading causes of death for both whites and blacks. 14

15 Table 5: Major Causes of Death and Race, and State 3-Year Age-Adjusted Death Rates by Cause, County State White Black All Races White Black All Races Total Deaths Cancer Heart Disease CLRD* Stroke Alzheimer s Disease Motor Vehicle Crashes Suicide Cirrhosis Diabetes Source: Florida Department of Health, Office of Vital Statistics *Chronic Lower Respiratory Disease Please note that due to the small size of the black population, a small number of deaths in one category can cause a large variance in the death rate for that category. Chart 8: Major Causes of Death and Race, 3-Year Age-Adjusted Death Rates by Cause Source: Florida Department of Health, Office of Vital Statistics 15

16 Leading Causes of Death Mortality rates can be key indicators of the state of health of a community. A significant number of s deaths are premature and preventable. Behavior modification and risk reduction can reduce the mortality rates of many of the leading causes of death, especially those attributed to heart disease, stroke, diabetes, lung cancer and motor vehicle accidents. Individuals may improve both the length and the quality of their lives by simply following a healthy lifestyle and receiving regular medical care. Table 6 gives detailed information on the leading causes of death for residents of in The Deaths column is a simple count of the number of people who died by the listed cause during Percent of Total deaths lets you know what percent of the people who died in 2012 died from that cause. Crude Rate per 100,000 gives a sense of how likely a person is to die of that cause in any given year. For example, out of every 100,000 people in, 51.4 of them died of a stroke in Using the rate per 100,000 allows comparison between areas with different populations such as comparing a small county to a large county or a county to the state. The next column lists the Age-Adjusted Death Rate per 100,000. Age-adjusting a rate is a way to make fairer comparisons between groups with different age distributions. For example, a county having a higher percentage of elderly people may have a higher rate of death or hospitalization than a county with a younger population merely because the elderly are more likely to die or be hospitalized. The same distortion can happen when we compare races, genders, or time periods. Age adjustment can make the different groups more comparable. The 3-Year Age-Adjusted Death Rate per 100,000 gives an average of the three years ending in 2012 (2010, 2011, and 2012). A small increase or decrease in the number of deaths in a given year can make a big difference in the rate so averages are used to flatten out large fluctuations. The last column is Years of Potential Life Lost. This is an estimate of the number of years a person would have lived had they not died prematurely. In this case that number is given for all people who died under the age of 75 assuming that they would have lived to the age of 75. When the numbers are particularly low, such as they are for Alzheimer s disease, it is generally because that cause of death largely impacts the elderly. Conversely, a particularly high number such as for unintentional injuries suggests that the average age of the victims was fairly young. 16

17 Cause of Death Table 6: Major Causes of Death For 2012 Deaths Percent of Total Deaths Crude Rate Per 100,000 Age- Adjusted Death Rate Per 100,000 3-Year Age- Adjusted Death Rate Per 100,000 YPLL <75 Per 100,000 Under 75 ALL CAUSES 2, % ,698 CANCER % ,599 HEART DISEASE % ,512 CHRONIC LOWER RESPIRATORY DISEASE % STROKE % ALZHEIMER S DISEASE % UNINTENTIONAL INJURY % ,344 DIABETES MELLITUS % CHRONIC LIVER DISEASE AND CIRRHOSIS % SUICIDE % ,255 PARKINSON S DISEASE % HYPERTENSION & HYPERTENSIVE RENAL DISEASE % BENIGN NEOPLASM % KIDNEY DISEASE % PNEUMONITIS DUE TO SOLIDS & LIQUIDS % CONGENITAL MALFORMATIONS % INFLUENZA & PNEUMONIA % SEPTICEMIA % AORTIC ANEURYSM & DISSECTION % HOMICIDE 8 0.3% GALLBLADDER DISORDERS 7 0.2% ATHEROSCLEROSIS 5 0.2% MEDICAL & SURGICAL CARE COMPLICATIONS 5 0.2% PERINATAL PERIOD CONDITIONS 4 0.1% VIRAL HEPATITIS 4 0.1% AIDS/HIV 3 0.1% PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 3 0.1% HERNIA 2 0.1% NUTRITIONAL DEFICIENCIES 2 0.1% PEPTIC ULCER 2 0.1% ANEMIAS 1 0.0% WAR OPERATIONS & SEQUELAE 1 0.0% Source: Florida Department of Health, Office of Health Statistics and Assessment Age-adjusted death rates are computed using the year 2000 standard population. YPLL = Years of Potential Life Lost 17

18 The most frequent causes of death for people in are cancer and heart disease. Together they accounted for 49.8 percent of the deaths in Table 7, which compares the three-year ageadjusted rates for with those for all of Florida, shows that the death rates in Collier County for cancer, heart disease, and diabetes are significantly lower than the state average. The death rate for is slightly higher than the state average for unintentional injuries, Alzheimer s disease, and chronic liver disease & cirrhosis. Table 7: Major Causes of Death Collier and State County Florida Age-Adjusted Age-Adjusted Rate/100,000 Rate/100,000 Cause of Death All Causes Cancer Heart Disease Unintentional Injury Chronic Lower Respiratory Disease Stroke Alzheimer s Disease Suicide Chronic Liver Disease & Cirrhosis Diabetes Source: Florida Department of Health, Office of Health Statistics and Assessment Age-adjusted death rates are computed using the year 2000 standard population. 18

19 Deaths from All Causes Table 8 lists the cause of death noted for all deaths in from The total number of deaths has fluctuated within a fairly narrow range during this period, with the lowest total in The death rate has fallen considerably during this same period, in part because the population of Collier County has increased by about 14.6 percent since Table 8: Deaths From All Causes All Races, All Sexes, All Ethnicities, All Ages Cause of Death All Causes 2,498 2,355 2,618 2,586 2,581 2,707 2,693 2,861 2,871 2,917 Infectious Diseases Certain other Intestinal Infections Human Immunodeficiency Virus (HIV) Disease Meningococcal Infection Other & Unspecified Infectious/Parasitic Disease & Sequelae Other Tuberculosis Respiratory Tuberculosis Salmonella Infections Septicemia Viral Hepatitis Malignant Neoplasm (Cancer) All Other & Unspecified - Cancer Bladder Cancer Breast Cancer Cervical Cancer Colon, Rectum, & Anus Cancer Corpus Uteri & Uterus, Part Unspec Cancer Esophagus Cancer Hodgkins Disease Kidney and Renal Pelvis Cancer Larynx Cancer Leukemia Lip, Oral Cavity, Pharynx Liver & Intrahepatic Bile Ducts Cancer

20 ...Meninges, Brain, & Other Part Cen Nerv Sys Cancer Multiple Myeloma & Immunoprolifera Neoplas Non-Hodgkins Lymphona Ovarian Cancer Pancreatic Cancer Prostate Cancer Skin Cancer Stomach Cancer Trachea, Bronchus, Lung Cancer In Situ, Benign, Uncert/Unk Behavior Neoplasms Anemias Nutritional and Metabolic Diseases Diabetes Mellitus Malnutrition Other Malnutritional Deficiencies Nervous System Diseases Alzheimer s Disease Meningitis Parkinsons Disease Cardiovascular Diseases Acute & Subacute Endocarditis Acute Myocardial Infarction Acute Rheum Fever & Chronic Rheum Heart Dis All Other Chronic Ischemic Heart Dis Aortic Aneurysm & Dissection Atherosclerosis Atherosclerotic Cardiovascular Disease Cerebrovascular Diseases Essen Hypertension & Hypertensive Renal Dis Heart Failure Hypertensive Heart & Renal Disease Hypertensive Heart Disease Other Acute Ischemic Heart Disease Other Arteries, Arterioles, Capillaries Other Forms Heart Dis

21 Pericardium Diseases & Acute Myocarditis Other Circulatory System Disorders Respiratory Diseases Asthma Bronchitis, Chronic & Unspecified Emphysema Other Chronic Lower Respiratory Diseases Influenza Pneumonia Other Respiratory System Dis Pneumoconiosis & Chemical Effects Pneumonitis Due To Solids & Liquids Digestive Diseases Appendix Diseases Cholelithiasis & Other Gallbladder Disorders Alcoholic Liver Disease Other Chronic Liver Disease & Cirrhosis Hernia Peptic Ulcer Urinary Tract Diseases Hyperplasia of Prostate Kidney Infections Acute/Progressive Nephritic/Nephrotic Synd Glomeruloneph, Nephri/Nephro, Renal Sclerosis Other Kidney Disorders Renal Failure Pregnancy, Childbirth, Puerperium Complications Perinatal Period Conditions Congenital & Chromosomal Anomalies Symptoms, Signs & Abnormal Findings Other Causes (Residual) External Causes Drowning & Submersion Falls Firearms Discharge Homicide by Firearms Discharge

22 ...Homicide By Other & Unspecified Means & Sequelae Medical & Surgical Care Complications Motor Vehicle Crashes Other & Unspecified Event & Sequelae Other & Unspecified Nontransport & Sequelae Other Land Transport Accidents Poisoning & Noxious Substance Exposure Smoke, Fire, Flames Exposure Suicide By Firearms Discharge Suicide By Other & Unspecified Means & Sequelae War Operations & Sequelae Water/Air/Space/Oth-Unsp Transport & seq Sudden Unexpected Infant Deaths Accidental suffocation and strangulation in bed Cause unknown/unspecified Other accidental suffocation and strangulation Sudden Infant Death Syndrome Source: Florida Department of Health, Office of Vital Statistics 22

23 Chronic Diseases Chronic diseases are those conditions defined as having a long duration and typically a slow progression. According to the Centers for Disease Control and Prevention, 75 percent of our nation s health care dollars goes to the treatment of chronic diseases. Seven out of every ten deaths in the United States each year are due to chronic diseases. Cancer Cancer is the leading cause of death in. Chart 9 gives a detailed look at the decline in deaths from all cancers across the last twenty years. The decline in is not as smooth as the decline at the state level, although it has been consistently lower in Collier than for the state as a whole. Despite a few higher years, the overall trend is mostly positive. In fact, had the lowest three-year rate of deaths from all cancers of all 67 counties in Florida for Chart 9: Deaths from All Cancers Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics 23

24 Cancer incidence in is fairly consistent with the state as a whole. After a brief climb in the early 1990s, is now seeing a slight downward trend. Chart 10: Cancer Incidence Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics Among the types of cancer, lung cancer causes the highest number of deaths in. The incidence of prostate cancer is significantly higher than the incidence of lung cancer in, but it is not nearly as deadly. Table 9: Common Types of Cancer Death Rate and Incidence, 3 yr. Age-Adjusted Death Rate, Avg. Annual Number of Events (Incidence), * Lung Cancer Breast Cancer Prostate Cancer Colorectal Cancer Cervical Cancer Skin Cancer Source: Deaths - Florida Department of Health, Office of Vital Statistics; Incidence - University of Miami (FL) Medical School, Florida Cancer Data System * is the most recent data available for annual number of cancer incidence. 24

25 An annual pap test is used to detect changes in the cells of the cervix, which can lead to cervical cancer. Detecting these abnormal cells early increases the chances of curing cervical cancer. According to the Behavioral Risk Factor Surveillance System 2010 Data Report (available in Appendix C), women over 18 years of age in were slightly less likely than women across the state as a whole to report that they had received a Pap test in the last year (54.1% Collier vs. 57.1% State). This rate is significantly lower than the rate in 2007 (62.9%). The rate is lowest for those women who make under $25,000 annually. Chart 11: Women 18 Years of Age or Older Who Received a Pap Test in the Past Year Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 25

26 Women ages 40 years and older are recommended to annually receive a mammogram, an x-ray of the breast, annually to detect and/or diagnose breast cancer. A higher percentage of women 40 years or older in reported that they had received a mammogram than the state average (69.3% Collier vs. 61.9% State). Income played a significant factor; women with incomes below $25,000 annually had the lowest rates. Chart 12: Women 40 Years of Age and Older Who Received a Mammogram in the Past Year Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 26

27 Residents of over the age of 50 indicated that they are less likely as of 2010 to have received a sigmoidoscopy or colonoscopy, screening exams for colorectal cancer, in the past five years than they did in 2007 (56.3% 2010 vs. 61.0% 2007), although that rate is nearly identical to the state average for 2010 (56.4%). Chart 13: Percentage of Adults 50 Years of Age and Older Who Received a Sigmoidoscopy or Colonoscopy in the Past Five Years Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 27

28 Similarly, there has been a decrease in the number of adults 50 years or older who indicated that they have received a blood stool test (12.5% 2010 vs. 20.3% 2007); these rates are lower than their counterparts across the state (12.5% Collier vs. 14.7% State). A blood stool test is another means of detecting colorectal cancer. Adults with incomes below $25,000 annually had the lowest rates across (2.1%) compared to those with incomes $25,000 to $49,999 (11.8%) or $50,000 and more (13.7%). Chart 14: Percentage of Adults 50 Years of Age and Older Who Received a Blood Stool Test in the Past Year Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 28

29 Heart Disease Heart disease is the second most common cause of death in, and the leading cause of death in the United States. As seen in Chart 15, age-adjusted death rates from heart disease have been on the decline for both and the state of Florida as a whole during this time period. Rates for are considerably lower than the state average. Chart 15: Deaths from Heart Disease Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics 29

30 According to the Centers for Disease Control and Prevention, coronary heart disease is the most common form of heart disease and can lead to a heart attack and/or angina (chest pain or discomfort). In, the percentage of adults who reported that they had ever had a heart attack, angina, or coronary heart disease was higher than for the state as a whole in 2010 (12.1% Collier vs. 10.2% State). Residents with lower annual incomes reported the highest rates. Chart 16: Adults Who Ever Had a Heart Attack, Angina, or Coronary Heart Disease Percentage by Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 30

31 Diabetes Deaths rates for diabetes in are much lower than those for cancer and heart disease, but are still a health concern. The age-adjusted three-year rates have fluctuated within a fairly narrow margin over the last twenty years, from a low of 9.4 per 100,000 ( ) to a high of 13.3 per 100,000 ( ), and have remained consistently lower than the state average. In fact, for the three year period of , ranked 2 nd lowest of the 67 counties in Florida with a rate of 9.4 per 100,000. (Martin County ranked the lowest with a rate of 9.3.) Chart 17: Deaths from Diabetes Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics 31

32 has a slightly lower rate of adults diagnosed with diabetes than the state (9.4% Collier vs. 10.4% State). The number of men reporting a diabetes diagnosis has increased from 2007 (12.5% 2010 vs. 9.5% 2007), but the number of women reporting this chronic condition has decreased (6.2% 2010 vs. 8.1% 2007). Chart 18: Adults with Diagnosed Diabetes Percentage by Sex, 2007 and 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 32

33 Residents with lower annual incomes reported much higher rates of diabetes than those with higher incomes. Residents with incomes lower than $25,000 annually reported a 16.8% rate in 2010, while those with incomes $50,000 or more only reported a 5.9% rate of diagnosed diabetes. Chart 19: Percentage of Adults with Diagnosed Diabetes Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. Of those adults who have been diagnosed with diabetes, more residents reported ever having participated in diabetes self-management education than the state as a whole (58.2% Collier vs. 55.1% State). 33

34 Communicable Diseases currently ranks below the state average rate for all sexually transmitted diseases and many vaccine preventable diseases. Note: It is possible that a larger number of individuals are positive for these diseases, but have not been tested. Table 10: Communicable Diseases and State County County State Disease # of Cases 3 yr. Rate 3 yr. Rate Annual Avg. per 100,000 per 100,000 Sexually Transmitted Diseases Infectious Syphilis Gonorrhea Chlamydia Vaccine Preventable Diseases Hepatitis B Measles Mumps Rubella Pertussis Tetanus AIDS and Other Diseases AIDS Meningococcal Meningitis Hepatitis A Tuberculosis Source: Division of Disease Control, Florida Department of Health 34

35 Sexually Transmitted Diseases Chlamydia is the most prevalent sexually transmitted disease in with an average of cases per year between 2010 and That works out to a rate per 100,000 of 226.6; much lower than the state average of The infection rate for chlamydia across the state of Florida has been on the rise for the last fifteen years, and has increased especially quickly in the last five years. The rates in have also seen a slight increase, but have remained well below the state rate over the past decade. For the three year period from ranked 9 th lowest out of 67 counties in Florida for the rate of chlamydia cases per 100,000 population. Chart 20: Chlamydia Cases 3-Year Rate per 100, Source: Florida Department of Health, Bureau of STD Prevention & Control 35

36 Vaccine Preventable Diseases The overall rate of infection from vaccine preventable diseases is very low in. For most of these diseases there is an average of less than one case every three years. Pertussis, a highly contagious respiratory disease that is commonly known as whooping cough, is the most prevalent vaccine preventable disease in with an average of 9.3 cases per year between 2010 and The disease usually starts with cold-like symptoms and maybe a mild cough or fever. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks. Whooping cough is most harmful to young babies. The Centers for Disease Control and Prevention (CDC) recommend pertussis vaccinations for children. The CDC further recommend that everyone who is around very young children be immunized as well. At a 3-year rate of 2.9 per 100,000, is seeing its highest rates in twenty years, fortunately there has not been a death attributed to pertussis in since Chart 21: Pertussis Cases 3-Year Rate per 100, Source: Florida Department of Health, Bureau of Epidemiology 36

37 AIDS and Other Diseases An average of 25.7 people per year was diagnosed with AIDS in between 2010 and The rate per 100,000 in is 7.9 compared to a rate of 16.3 for the state as a whole. The largest number of those cases come from urban areas. These numbers have been declining over recent years. The 3-year rate per 100,000 residents has decreased 54 percent over the past decade (17.1 per 100,000 in vs. 7.9 per 100,000 in ) Chart 22: AIDS Cases 3-Year Rate per 100, Source: Florida Department of Health, Bureau of HIV/AIDS The rate of tuberculosis, an infectious bacterial disease, in is higher than the state as a whole at 5.5 per 100,000 compared to 2.9 per 100,000. While these numbers are higher than the state average, they are considerably lower than in years passed. had a 3-year high of 19.2 per 100,000 in , and has seen a fairly steady decline in the years since. Chart 23: Tuberculosis Cases 3-Year Rate per 100, Source: Florida Department of Health, Bureau of TB and Refugee Health 37

38 Maternal and Child Health On average, 3,228.0 babies were born per year in between 2010 and The health of the babies, the care they received before birth and the age of the mothers are important factors in determining the state of maternal and child health which in turn is a large factor in the overall health of the county. Babies born to young mothers under the age of 19 are more likely to experience poor birth outcomes than those born to adult mothers and are more at risk for developmental complications later in life. The rates in for births to teenage mothers are very similar to the state, and have been declining in recent years. Infant mortality rates are considered a primary indicator of the health of a community. These rates document the deaths of babies between birth and 364 days of life. The leading causes of infant deaths in Florida are perinatal conditions, congenital anomalies, low birth weight and sleep-related deaths. There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Infant mortality rates for this time period in are slightly lower than the average for the state of Florida, and continue to decline. Table 11: Maternal & Child Health Indicators, & State 3-Year Figures, Births County State Trend Quartile* Total Births (3-yr annual avg.) 3, Births to Mothers ages 15-44, per 1, Births to Mothers ages 10-14, per 1, Positive 2 Births to Mothers ages 15-19, per 1, Positive 1 Percent of Births to Unwed Mothers Positive 2 Infant Deaths Infant Deaths (0-364 days) per 1,000 Births Positive 1 Neonatal Deaths (0-27 days) per 1,000 Births Positive 2 Postneonatal Deaths ( days) per 1,000 Births Steady 2 Low Birth Weight Percent of Births < 1500 Grams Steady 2 Percent of Births < 2500 Grams Steady 1 Prenatal Care Percent of Births with 1st Trimester Prenatal Care Steady 1 Percent of Births with Late or No Prenatal Care Positive 4 Source: Florida Department of Health *County compared to other Florida counties. The lowest Quartile equals the lowest number. That is not always the most desirable rate. For instance, it would be desirable to have a quartile of 4 for percent of births with 1 st trimester care; however it would be desirable to have a quartile of 1 for infant deaths. 38

39 Mothers Who Smoked During Pregnancy Mothers who smoke during pregnancy are putting their unborn child(ren) at a higher risk for low birth weight and Sudden Infant Death Syndrome (SIDS). Fortunately, mothers have low rates of smoking during pregnancy. s rates have been consistently lower than that of the state. For 2012, had a rate of 3.0 births per 1,000 to mothers who smoked during pregnancy, as compared to the state average of 6.6 births per 1,000. was ranked 5 th healthiest out of all 67 counties in Florida for this health indicator for This rate has seen a 78 percent decrease over the past twenty years, from a high of 13.7 births per 1,000 to mothers who smoked during pregnancy in 1993 to its lowest rate of 3.0 births per 1,000 in Chart 24: Births to Mothers who Smoked During Pregnancy Single Year Rate per 1,000 Source: Florida Department of Health, Bureau of Vital Statistics 39

40 Teen Births In 2012, saw its lowest rates of live births to teenage and pre-teen mothers (11.9 births per 1,000). had rates of teen births consistently higher than the rates for the state of Florida until Rates for both the state and have been declining. currently has the 14 th lowest rate out of all 67 counties in Florida for births to mothers ages Chart 25: Births to Mothers ages Single Year Rate per 1,000 Source: Florida Department of Health, Bureau of Vital Statistics Infant Deaths Infant deaths in have declined consistently since the most recent peak in 2009 (7.4 per 1,000 births). There were thirteen infant deaths in 2012 (4.1 per 1,000 births). Chart 26: Infant Deaths (0-364 days) Single Year Rate per 1,000 births Source: Florida Department of Health, Bureau of Vital Statistics 40

41 Senior Citizen Health Over the past twenty years, the elderly population (those 65 and older) in has seen an increase of 96%. The overall population of has only increased 79% during that same time. The number of residents who are 85 and older has increased 234% during that time. As this unique population continues to grow in, their unique health concerns continue to grow as well. The population in age 65 and over tends to have a higher median income than residents of the same age across the state of Florida as well as throughout the United States. While higher income does not necessarily equate to better health, it does play a role in an individual s health. Table 12: Median Household Income by Age 2010 Collier Florida United States less than 25 $16,603 $23,640 $24, to 44 $48,253 $47,993 $54, to 64 $60,859 $52,102 $60, and over $51,419* $35,024 $34,381 Source: U.S. Census American Community Survey * was ranked the highest county in Florida for median household income for persons age 65 and over in The overall crude death rate for residents age 65 and over in 2012 was 2,699.3 per 100,000. This is a 4.4 percent decrease from For residents age 65 and over, the leading causes of death most recently have been cancer, heart disease, chronic lower respiratory disease, Alzheimer s disease and unintentional injuries. Alzheimer s disease in particular has seen a large rise in the total number of deaths over the past ten years by those age 65 and over in Collier County. Table 13: Leading Causes of Death, Residents 65 and over Total Number of Deaths*, Total Cancer ,543 Heart Diseases ,504 CLRD** ,399 Cerebrovascular Diseases ,337 Alzheimer s Disease ,064 Unintentional Injury Source: Florida Department of Health, Office of Vital Statistics *Please note these are raw counts. Some fluctuations in counts may be due to changes in the population. **Chronic Lower Respiratory Disease 41

42 Alzheimer s Disease has seen a dramatic increase in recent years in the rate of deaths attributed to Alzheimer s disease, the most common form of dementia. The three-year age-adjusted rate for Collier County for (23.1 per 100,000) is nearly four times the lowest rate for the county over the past twenty years (6.2 per 100,000 for ). This rate is also higher than the state average for (23.1 Collier vs State). In fact, compared to the rest of the state, Collier ranked 47th out of 67 counties for age-adjusted Alzheimer's disease death rates for Chart 27: Deaths from Alzheimer s Disease Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics 42

43 As stated previously, women in tend to have a longer than average life-expectancy. The largest risk factor for acquiring Alzheimer s disease is an increase in age, which can explain why more women than men in have had Alzheimer s listed as their cause of death in recent years. Chart 28: Deaths from Alzheimer s Disease, by Sex Age-adjusted rate per 100,000, 3-Year Rates Source: Florida Department of Health, Bureau of Vital Statistics has ten nursing homes (skilled nursing facilites), with a total of 908 beds. This is a rate of beds per 100,000 population, which is much lower than the state average of per 100,000 even though the percent of persons over 65 is higher than the state average. Of those 908 beds, 65 are in secured units that are designated for those who are cognitively impaired (such as residents with dementia and Alzheimer s disease). These are needed units, with an overall occupancy rate of 97.6 percent for January 2012 through December 2012, with several months at 100% occupancy. 43

44 Oral Health Oral health is felt to be central to a person s overall health and well-being. In 2000, Surgeon General David Satcher released the first-ever report on oral health, in which he found that there were significant disparities between racial and socioeconomic groups with regards to oral health, and the the medical complications that can result from minimal oral care and treatment. According to the Behavioral Risk Factor Surveillance System 2010 Data Report (available in Appendix C), a larger percentage of adults in reported that they had visited a dentist or dental clinic in the past year than the same for the state (73.3% Collier vs. 64.7% State). Women were more likely than men to have reported a visit to a dentist of dental clinic (68.5% men vs. 78.2% women). Persons with higher annual incomes reported significantly higher rates of dental visits percent of persons with annual incomes of $50,000 or more reported visiting a dentist or dental clinic in the past year while only 40.6 percent of those with incomes under $25,000 annually only reported having visited a dentist of dental clinic. Chart 29: Adults Who Visited a Dentist or Dental Clinic in the Past Year Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 44

45 residents reported lower rates of having a permanent tooth removed because of tooth decay or gum disease than adults across the state (48.4% Collier vs. 53.0% State). Income levels, again, played a role in the percentage of these procedures amongst residents. Chart 30: Adults Who Had a Permanent Tooth Removed Because of Tooth Decay or Gum Disease Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 45

46 The same holds true for the percentage of adults who had their teeth cleaned in the past year. Overall 69.2 percent of adult residents had their teeth cleaned compared to 60.9 percent of adults across the state of Florida. Those with higher income levels were significantly more likely to have had a cleaning. Chart 31: Adults Who Had Their Teeth Cleaned in the Past Year Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 46

47 Accessibility for Low-Income Residents According to data from the Florida Department of Health Public Health Dental Program, residents who are living below the poverty level have seen in increase in their access to dental care over recent years. While the percentages are still low (36.3% in 2010), they are on par with the state of Florida as a whole, and the most recent year s data is 20 percent higher than in Chart 32: Percentage of Low-Income Persons* with Access to Dental Care Single Year Rate Source: Florida Department of Health, Public Health Dental Program *Low-Income Persons are defined as those living below the poverty level. Figure 3: Source: Florida Department of Health, Public Health Dental Program 47

48 Access for many low-income individuals means having health care coverage through the Medicaid program. Health care providers are not required to see Medicaid patients. For those low-income persons living in who are Medicaid-eligible, there are few options for dentists who accept Medicaid, and the dental services that Medicaid will cover are limited. As of August 2013, there were five Medicaid dental providers in (744 statewide). This number includes county health departments and federally qualified health centers (see Appendix J for full list of Medicaid dental providers). Medicaid is discussed in more detail in the Health Resources section of this assessment. There are other dental providers in the county who do not accept Medicaid, but offer services to low-income residents, such as the Neighborhood Health Clinic and the Senior Friendship Center. The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, has designated as a Health Professional Shortage Area (HPSA) for dental care in the Immokalee/Everglades Service Area. According to federal calculations, the Immokalee/Everglades Service Area should have seven dentists serving the low-income population and migrant farmworker population; there is currently a shortage of five dentists. HPSAs are discussed further in the Federal Health Professional Shortage Designations section of this assessment. 48

49 Dental Emergencies A lack of access to dental care can lead to avoidable visits to the local emergency room and avoidable hospitalizations. In 2012, residents made 817 emergency room visits for dental conditions that are typically considered avoidable with appropriate preventative care. The charges for these avoidable visits totaled $580,642. Table 14: Avoidable Emergency Department Visits for Dental Conditions as Patient s Reason for Visit Residents, January 2012 through December 2012 Facility Total Emergency Department Visits* Average Charges Total Charges NAPLES COMMUNITY HOSPITAL 263 $627 $164,891 NCH HEALTHCARE SYSTEM NORTH NAPLES HOSPITAL CAMPUS 194 $518 $100,564 PHYSICIANS REGIONAL MEDICAL CENTER COLLIER BOULEVARD 218 $862 $187,978 PHYSICIANS REGIONAL MEDICAL CENTER PINE RIDGE 142 $896 $127,209 TOTAL 817 $711 $580,642 Source: Florida Health Finder Emergency Department Query. Available at Accessed August 15, *The data shown does not include emergency department visits that resulted in an admission to the hospital. Preventable hospitalizations for residents under 65 years of age have steadily risen over the last several years. The rate per 100,000 has remained below the Florida rate until 2011, when s rate surpassed it (10.5 Collier vs State). Chart 33: Preventable Hospitalizations Under 65 from Dental Conditions Single Year Rate per 100, Source: Florida Agency for Health Care Administration (AHCA) 49

50 Social and Mental Health The status of the social and mental health of a community plays a large role in that community s overall health. Rates of criminal activity, substance abuse, and suicides all contribute to the well-being of a community. Crime and Domestic Violence In several categories ranks amongst the best quartile for crime in the state of Florida. ranks below the state average for all categories of crime and domestic violence, and ranks in the 1 st Quartile for burglary, aggravated assault, and motor vehicle theft. Table 15: Crime and Domestic Violence 3-Year Rate per 100,000, County State Quartile* Larceny 1, , Total Domestic Violence Offenses Burglary Aggravated Assault Motor Vehicle Theft Robbery Forcible Sex Offenses Murder Sources: Florida Department of Law Enforcement *County compared to other Florida Counties. The lowest Quartile equals the lowest number. Larceny, which is a common law crime involving theft, had the highest rates of all of the crime and domestic violence indicators in. These rates, although high, have seen a steady decline from a high in of per 100,000 population. ranked 19 th out of the 67 counties in Florida for the three-year rate from Chart 34: Larceny in 3-Year Rate Per 100,000 Population Source: Florida Department of Law Enforcement 50

51 Domestic violence offenses in have been on the decline in recent years, and are currently lower than the state rate. For the three year period from , had a rate of domestic violence offenses per 100,000 population, compared to the state average of Since 1994, s rate of domestic violence offenses has decreased 32.6 percent. Chart 35: Total Domestic Violence Offenses Rate per 100,000, 3-Year Rates Source: Florida Department of Law Enforcement The most reported domestic violence offense in is simple assault. Simple assaults account for over seventy-five percent of all domestic violence offenses in. Please note that these figures are for offenses that were reported to law enforcement. Instances of these offenses often take place but are not reported. Table 16: Reported Domestic Violence Offenses, Murder Manslaughter Forcible Rape Forcible Sodomy Forcible Fondling Aggravated Assault Aggravated Stalking Simple Assault 1,386 1,406 1,295 1,411 1,398 1,265 1,318 Threat/Intimidation Stalking Total 1,911 1,911 1,742 1,784 1,764 1,655 1,613 Source: Florida Department of Law Enforcement 51

52 Alcohol-related Motor Vehicle Crashes In 2011 residents were involved in 1,795 motor vehicle traffic crashes. Of these, 14.8% (265 crashes) were alcohol-related. In that same year there were 31 motor vehicle traffic crash deaths; 48 percent (15 deaths) were alcohol-related. Chart 36: Motor Vehicle Crash Deaths in Total Deaths and Alcohol-related Deaths, Source: Florida Department of Health, Bureau of Vital Statistics, and Florida Department of Highway Safety and Motor Vehicles When compared to the state average, had lower rates for all of the alcohol-related motor vehicle crash indicators for the three year period from 2009 to ranked in the 1 st Quartile for each indicator. Table 17: Alcohol-related Motor Vehicle Crashes 3-Year Rate per 100,000, County State Quartile* Alcohol-related Motor Vehicle Crashes Alcohol-related Motor Vehicle Crash Injuries Alcohol-related Motor Vehicle Crash Deaths Sources: FDLE Uniform Crime Report, DHSMV Traffic Crash Facts, Florida Office of Vital Statistics *County compared to other Florida Counties. The lowest Quartile equals the lowest number. 52

53 The percent of adults who reported on the Behavioral Risk Factor Surveillance System survey that they engage in heavy or binge drinking in increased from 16.1 percent in 2007 to 19.2 percent in This percentage is higher than the state average of 15.0 percent. The rate of heavy and binge drinking is higher for men than for women in (22.2 men vs women). The highest rate is among people between 18 and 44 (23.6) and lowest among people over the age of 65 (12.6). Persons with higher income levels reported drinking at higher rates than those with lower annual incomes. In fact, more than double the number of residents with annual incomes of $50,000 or more reported that they engage in heavy or binge drinking than those with annual incomes of less than $25,000. Singles were less likely to drink heavily than persons who are married. Chart 37: Percentage of Adults who Engage in Heavy or Binge Drinking Percentage By Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 53

54 Florida Youth Substance Abuse Survey The Florida Youth Substance Abuse Survey (FYSAS) is a collaborative effort between the Florida departments of Health, Education, Children and Families, Juvenile Justice, and the Governor's Office of Drug Control. It is based on the "Communities That Care" survey, which measures the prevalence and frequency of drug use, the prevalence and frequency of other antisocial behaviors, and the degree to which risk and protective factors exist that can predict alcohol, tobacco, and other drug use, delinquency, gang involvement and other problem behaviors in adolescents. The FYSAS was administered to 70,859 students in grades 6 through 12 in February and March of Across Florida, 417 middle schools and 329 high schools administered the surveys. In, 1,204 students completed the survey (548 middle school students; 656 high school students). The survey has been administered annually since 2000, making the 2012 FYSAS the thirteenth set of data. Alcohol use in the past 30 days was 27.2 percent for students in 2012, which was slightly higher than the state average of 24.6 percent had the lowest percentage of students reporting that they had used alcohol in the past 30 days in the years surveyed, with a peak of 35.5 percent in Chart 38: Past-30-Day Alcohol Use and Florida Statewide 2012 Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 54

55 Similarly, the percentage of students reporting cigarette use over the past 30 days in in 2012 was slightly higher than the Florida average (7.6% Collier vs. 6.6% State). This is lower for Collier County than past years, with a high of 13.7 percent in Males are more likely to report cigarette use than females (8.8% males vs. 6.6% females). Chart 39: Past-30-Day Cigarette Use and Florida Statewide 2012 Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Past-30-day marijuana use for students in 2012 was similar to students across the state as a whole (12.2% Collier vs. 12.4% State). The overall percentage of students who have reported marijuana use has remained fairly consistent since 2002, from a low of 10.5 percent in 2010 to a high of 12.2 percent in High school students surveyed were more than three times as likely to have used marijuana as middle school students (17.5% high school students vs. 5.0% middle school students). Chart 40: Past-30-Day Marijuana Use and Florida Statewide 2012 Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 55

56 The FYSAS asks youth if they have ever used various drugs. Table 18 below illustrates the high incidence of youth having ever tried alcohol, cigarettes, and marijuana in particular. Also relatively high were the percentage of high school students in 2012 who reported having ever used synthetic marijuana (14.0%), and the percentage of middle school students who reported having ever used inhalants (9.7%). These rates are similar to Florida s statewide averages for the same substances. Table 18: Percentages of Youth Who Reported Having Used Various Drugs in their Lifetimes 2012 Middle School High School Overall Florida Statewide Middle High School School Overall Alcohol Cigarettes Marijuana or Hashish Synthetic Marijuana Inhalants Club Drugs LSD, PCP or Mushrooms Methamphetamine Cocaine or Crack Cocaine Heroin Depressants Prescription Pain Relievers Prescription Amphetamines Steroids (without a doctor's order) Over-the-Counter Drugs Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families The symbol indicates that data are not available. Additional tables from the Florida Youth Substance Abuse Survey are available in Appendix I. 56

57 Suicides Suicides can be considered as a strong indicator of the overall mental health of a community. The most common underlying causes of suicide are depression, anxiety, damaged relationships and loss of employment. Suicide is a major, preventable public health problem. The suicide rate for has been slowly declining over the last twenty years, decreasing about twenty-five percent since 1993 ( vs ). The most recent 3-year rate per 100,000 is below the state average (12.5 Collier vs State). Of the 67 counties in Florida, ranked 18 th lowest for the age-adjusted suicide death rate. Chart 41: Age-Adjusted Suicide 3-Year Death Rate 3-Year Age-Adjusted Death Rate Per 100,000 Population Source: Florida Department of Health, Bureau of Vital Statistics. 57

58 Baker Act The Florida Mental Health Act of 1971 (commonly known as the "Baker Act") is a statute allowing for involuntary examination of an individual. It was originally enacted, at least in part, because of widespread instances of elder abuse in which one or more family members would have another family member committed in order to gain control over their estate prior to their death. Once committed, it was difficult for many of the patients to obtain representation, and they became warehoused until their death. The Baker Act allows for involuntary examination (what some call emergency or involuntary commitment). It can be initiated by judges, law enforcement officials, physicians or mental health professionals. There must be evidence that the person has a mental illness (as defined in the Baker Act) and is a harm to self, harm to others, or self-neglectful (as defined in the Baker Act). Examinations may last up to 72 hours and occur in over 100 facilities statewide. There are many possible outcomes following examination of the patient. This includes the release of the individual to the community (or other community placement), a petition for involuntary inpatient placement (what some call civil commitment), involuntary outpatient placement (what some call outpatient commitment or assisted treatment orders), or voluntary treatment (if the person is competent to consent to voluntary treatment and consents to voluntary treatment). There were 1,169 involuntary examinations in in This number has risen fifty-six percent since 2002 (748 involuntary examinations). The rate per 100,000 of the population in Collier County that was given an involuntary exam in 2012 was lower than the state rate (357.4 Collier vs State). Of those in, 64.1 percent were initiated by law enforcement, 35.5 percent were initiated by mental health professionals, and less than 1 percent were initiated by judges. Chart 42: Involuntary Examinations* Single Year Rate Per 100,000 Population Source: 2007, 2008, 2009, 2010, 2011, 2012 Florida Mental Health Act (The Baker Act) Reports / Baker Act Reporting Center at FMHI/USF *Involuntary examination forms for people who never reach a receiving facility are not received by the Baker Act Reporting Center, so are not included in the data. 58

59 Hospitalizations The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care-sensitive conditions." These are conditions for which good outpatient or preventative care can potentially eliminate the need for hospitalization or for which early intervention can prevent complications or more severe disease. Even though these indicators are based on hospital inpatient data, they provide insight into the community health care system or services outside the hospital setting. For instance, patients with diabetes may be hospitalized for diabetic complications if their conditions are not adequately monitored or if they do not receive the patient education needed for appropriate self-management. Full definitions for each of the PQIs are available in Appendix H. Congestive heart failure, bacterial pneumonia, urinary infections, and chronic obstructive pulmonary disease (this category includes chronic bronchitis and emphysema) are the most common preventable causes of hospitalizations for residents. s 2011 rates of congestive heart failure and dehydration were higher than the state of Florida as a whole. Since 2006, rates of urinary infection have more than doubled ( vs ). Table 19: Prevention Quality Indicators Annual Rate per 100, , Florida PQI Diabetes/short-term Diabetes/long-term Chronic obstructive PD Hypertension Congestive HF Dehydration Bacterial pneumonia Urinary infections Angina w/o procedure Uncontrolled diabetes Adult asthma Diabetes/LE amputations Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of residents in any hospital in Florida. 59

60 The Chronic Condition Indicator tool is another method to look at the health of a community through hospitalizations. This tool stratifies chronic diseases based on ICD-9-CM diagnosis codes. A chronic condition is a condition lasting 12 months or longer and meeting one or both of the following tests: (a) the condition places limitations on self-care, independent living and social interactions; (b) the condition results in the need for ongoing intervention with medical products, services and special equipment. The identification of chronic conditions is based on all five-digit ICD-9-CM diagnosis codes, excluding external cause of injury codes (E codes). The data from this tool tells a similar story as the PQI data. Hypertension is the number one cause of hospitalization for a chronic condition and the rates are rising. The hospitalization rates for diabetes, congestive heart failure, and sickle cell are also on the rise. Table 20: Hospitalizations for Chronic Conditions Annual Figures, , Residents Disease Diabetes 5,257 5,137 5,876 6,413 6,838 Asthma 1,819 1,963 1,976 2,021 2,056 Congestive Heart Failure 3,896 3,636 4,031 4,129 3,908 Hypertension 11,292 11,527 12,163 13,346 14,031 AIDS Sickle Cell Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of residents in any hospital in Florida. 60

61 Emergency Room Visits Residents made 73,736 visits to hospitals in 2011 that did not result in an inpatient admission. The largest number of visits was made to North Naples Hospital. The next largest numbers of visits were made to Physicians Regional Medical Center Collier Blvd., Downtown Naples Hospital, and Physicians Regional Medical Center Pine Ridge. Table 21: Emergency Room Visits by Residents by Payer Source 2011 Medicaid Medicare No charge/ Charity Other Private, incl. HMO Self- Pay* Grand Total NCH Healthcare System North Naples Hospital 6,780 3, ,210 4,426 20,438 Physicians Regional Medical Center Collier Blvd 7,674 2, ,200 3,184 17,462 Downtown Naples Hospital 2,560 5, ,423 3,656 15,563 Physicians Regional Medical Center - Pine Ridge 3,775 3, ,624 2,463 13,826 Lehigh Regional Medical Center 1, ,050 Healthpark Medical Center 1, ,505 Gulf Coast Medical Center Lee Memorial Hospital Jackson Memorial Hospital Tallahassee Memorial Hospital Broward General Medical Center Charlotte Regional Medical Center Shands Hospital At The Univ. Of Florida Cape Coral Hospital Cleveland Clinic Hospital Memorial Regional Hospital Tampa General Hospital Miami Children's Hospital University Community Hospital Sarasota Memorial Hospital Total 23, % 14, % % 2, % 16, % 15, % 73, % Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System The AHCA ED data contains records for all ED visits for which the severity of the visit did not result in an inpatient admission. Includes visits by residents to the ED of any hospital in Florida. *Charges billed as self-pay often end up as no charge/charity if the patient is unable to pay the bill. Only hospitals with at least 35 visits are included in the table above. There are an additional 1,501 visits divided amongst 177 hospitals that have not been included in the table, but are included in the total. 61

62 Health Resources Access to health care is the key to achieving a healthy community and is a primary goal of health policy in Florida. This section will review health coverage of residents including the rate of uninsured residents, licensed providers and facilities, and federal health professional shortage designations percent of adults in reported on the Behavioral Risk Factor Surveillance System survey that they were unable to see a doctor at least once in the previous year due to cost. This is better than the state average of 17.3 percent. More men reported not being able to see a doctor in the past year due to cost than women in Chart 43: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Sex, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 62

63 Annual income and age had the greatest effect in residents ability to see a doctor. Residents with annual incomes $50,000 or more only reported not being able to see a doctor due to cost at a rate of 4 percent, while those with annual incomes below $25,000 reported a rate of 35.6 percent. Chart 44: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 63

64 Older residents had significantly less difficulty seeing a doctor than their younger counterparts. Chart 45: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Age, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 64

65 73.1 percent of adults in reported that they had a medical checkup in the past year; this is better than the state average of 69.7 percent. Annual income played a role in how likely residents were to have had a medical checkup. Those with annual incomes between $25,000 and $49,999 had the highest rates (80.0%) of all income groups. Chart 46: Percentage of Adults who had a Medical Checkup in the Past Year Percentage by Income, 2010 Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. 65

66 Medicaid Medicaid provides medical coverage to low-income individuals and families. The state and federal government share the costs of the Medicaid program. Medicaid services in Florida are administered by the Agency for Health Care Administration (AHCA). About half of the recipients are children or adolescents under the age of 21. While children are the largest category of beneficiaries, most of the costs arise from providing services to seniors, especially nursing home care, as well as to people with disabilities who have significant medical costs. There are four categories of Medicaid eligibility for adults in Florida, which include low-income families, pregnant women, emergency medical assistance for non-citizens, and Medicaid for the elderly and disabled. Eligibility for each of those programs is based on specific income criteria. As of 2011, approximately 12,500 out of every 100,000 people in were enrolled in Medicaid; the state rate is approximately 16,500 per 100,000. At both the state and the county level, there was a sharp increase in the number of people enrolled in Medicaid between 2007 and Both rates have continued to climb since then. has the 12 th lowest Medicaid enrollment rates out of the 67 counties in Florida. Chart 47: Median Monthly Medicaid Enrollment Single-Year Rate Per 100,000 Population Source: Florida Department of Health, Office of Planning, Evaluation & Data Analysis A full list of Medicaid primary care providers is available in Appendix J. 66

67 Florida KidCare Florida KidCare is the state-funded children s health insurance program for those who are uninsured from birth to age 19 and meet income and eligibility requirements. Three state agencies and the Florida Healthy Kids Corporation work together to form KidCare. The four components of Florida KidCare are: Medicaid for Children from birth to 19 (see previous section on Medicaid) Florida Healthy Kids for children ages 5 to 18 who are ineligible for Medicaid or Children s Medical Services Network (families pay a monthly premium, based on their income) MediKids for children ages 1 to 4 (families pay a monthly premium, based on their income) Children s Medical Services (CMS) Network for children with special health care needs up to 200% of the Federal Poverty Level Table 22: Monthly Children s Health Insurance Enrollment Florida Healthy Kids MediKids CMS Total Active Children July, , ,777 August, , ,810 September, , ,818 October, , ,841 November, , ,877 December, , ,811 January, , ,841 February, , ,898 March, , ,892 April, , ,938 May, , ,024 June, , ,010 Source: Florida Healthy Kids Corporation Chart 48: Total Monthly Children s Health Insurance Enrollment Source: Florida Healthy Kids Corporation 67

68 Uninsured Lack of health insurance coverage is a significant barrier to accessing needed health care. Those who are uninsured are less likely to receive preventive care, and more likely to delay needed medical treatments which, often leads to costly visits to the local Emergency Department. The Small Area Health Insurance Estimates from the U.S. Census Bureau provide annual estimates of the population without health insurance coverage for all U.S. states and their counties. The most recent year for which reliable county-level estimates are available is The rate of uninsured adults represents the estimated percent of the adult population under age 65 that has no health insurance coverage. People over the age of 65 are eligible for Medicare from the federal government. As of 2011, was estimated as having 33.3 percent of adults without health insurance; this compares to a rate of 29.3 percent for Florida as a whole. This number is a 3.9 percent decrease from 2006, but is on the rise after a low of 31.4 percent in In 2011 had the 7 th highest percentage of uninsured adults out of the 67 counties in Florida. Chart 49: Uninsured Adults (Age 18 64) Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 68

69 As would be expected, those with income levels near and below the Federal Poverty Level ($22,350 for a family of 4 in 2011) had the highest rates of uninsured adults. In 2011, 63.4% of adults with incomes at or below 138% of the Federal Poverty Level (FPL) were uninsured. adults with incomes above 400% of the FPL only had a rate of 9.4% being without health insurance. Chart 50: Uninsured Adults (Age 18 64) Percentage by Income (based on Federal Poverty Level), 2011 Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 69

70 While the percentage of adults who are uninsured has increased since 2008, residents under the age of 19 have seen the opposite trend. Since 2006, the number of uninsured youth has decreased 10.5 percent to a low of 16.0 percent in The state as a whole has seen a similar trend, with rates at a low of 12.5 percent of uninsured youth in In 2011 had the 5 th highest percentage of uninsured youth of the 67 Florida counties. Chart 51: Uninsured Youth (Under 19 Years) Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) As with the adult population in, youth living in households with income levels near and below the Federal Poverty Level had the highest rates of being uninsured. Chart 52: Uninsured Youth (Under 19 Years) Percentage by Income (based on Federal Poverty Level) 2011 Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 70

71 Physicians and Facilities As of 2011, there were eight hundred and seventy licensed physicians in. That works out to doctors for every 100,000 residents. That is a slightly lower rate than the state average of 342 doctors for every 100,000 residents. The county has a much lower rate per 100,000 than the state for licensed pediatricians (14.8 Collier vs State). The number of Health Department employees per every 100,000 residents is lower than the state average. The Health Department spent $12,016,300 dollars in 2011; that places the rate of expenditure per 100,000 residents at slightly lower than the state average. Providers* Table 23: Health Resources Availability & State 2011 County Number Rate per 100,000 Quartile** State Rate per 100,000 Total Licensed Dentists Total Licensed Physicians Total Licensed Family Private Practice Physicians Total Licensed Internists Total Licensed OB/GYN Total Licensed Pediatricians Facilities Total Hospital Beds Total Acute Care Beds Total Specialty Beds Total Skilled Nursing Home Beds County Health Department County Health Department Full-Time Employees County Health Department Expenditures 12,016,300 3,703, ,204,339 Source: Division of Medical Quality Assurance and Office of Planning, Evaluation and Data Analysis, Florida Department of Health; Florida Agency for Health Care Administration *Data for Providers are for a fiscal year, not a calendar year Number of licensed providers does not necessarily equal the number of practicing providers. These numbers may include providers who work in another county, only work part time, or are retired. **County compared to other Florida counties. The lowest Quartiles equal the lowest number. For resource availability the lowest number is generally considered the worst ranking. 71

72 Federal Health Professional Shortage Designations There are two types of health professional shortage designations: Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas or Populations (MUAs/MUPs). Both designations consider primary care physician-to-population ratios, other high-need indicators (poverty levels, percent of the population that is elderly, infant death rate and rate of low birth weight), and barriers to access care. Designations are required for placement of health professionals under the National Health Service Corps and waiver programs for foreign physicians. Designations are also necessary for the location of community and migrant health centers and rural health clinics, programs that provide health care to underserved populations. Medically Underserved Areas or Populations (MUAs/MUPs) are a measure of medical under service as defined by the U.S. Department of Health and Human Services. These designations determine the Index of Medical Under service (IMU) using the following variables: (1) percent of the population below 100 percent of the Federal Poverty Level, (2) percent of the population over age 65, (3) infant mortality rate (5 year average) and (4) population-to-physician ratio. s Low Income/Migrant Farmworker Populations have been designated as Medically Underserved Populations. Any population with a score of 65 or lower on the Index of Medical Underservice is considered medically underserved. s Low Income/Migrant Farmworker Populations scored a Health Professional Shortage Areas (HPSAs) are defined in Section 332 of the Public Health Service Act, 42 U.S.C. 254e to include: (1) urban and rural geographic areas, (2) population groups, and (3) facilities with shortages of health professionals. Federal designation as a HPSA documents a shortage of health care providers (primary care, dental or mental health) as well as the existence of barriers to accessing care including lack of public transportation, travel time and distance to the next source of undesignated care and high poverty. To be eligible for designation, a geographic area or a population group (a low income or migrant population) must have a population-to-physician ratio greater than 3,000 to one. What a Designation Means A geographic designation for the whole county means there is a shortage of providers (primary care physicians, dentists, mental health professionals) for everyone living in the county, regardless of ability to pay for services through insurance or other means. A geographic area within the county means there is a shortage of health care providers for everyone living in that area of the county. A special population designation for the whole county (or parts of counties) means there is a shortage of providers to meet the needs of low income, migrant or other special populations because the existing providers do not serve these patients. 72

73 has been designated as a Health Professional Shortage Area (HPSA) for primary care in the Immokalee/Everglades Service Area. According to federal calculations, the Immokalee/Everglades Service Area should have nineteen primary care doctors serving the population; there is currently a shortage of ten doctors. HRSA calculated that the Immokalee/Everglades area requires seven dentists serving the low-income population and migrant farmworker populations; there is currently a shortage of five dentists. 73

74 Community Input Survey on Health and Healthcare in The Health Planning Council of Southwest Florida, with feedback from the HcN Community Health Assessment Group, developed a survey questionnaire to assess residents perceptions of healthcare and health issues for the county. The survey was conducted online and on paper, in both English and Spanish. Surveys were distributed by members of the HcN Community Health Assessment Group to those who live and/or work in. Links to the online version of the survey were distributed through flyers and blasts. The English version of the survey is included in Appendix D. 295 surveys were completed on paper and online over a two month period in the spring of 2013 (237 in English, 58 in Spanish). 88 percent of survey respondents were permanent residents, 6 percent were seasonal and 6 percent were temporary residents. Fifty-nine percent reported living in a Naples zip code; 35 percent reported living in an Immokalee zip code. The survey garnered responses from a slightly higher proportion of respondents ages 18 to 34 than in the overall adult population in (39% of survey respondents vs. 21% of adults in that age range in ). There were also more females who responded to the survey than in the adult population in (81% of survey respondents were female vs. 51% of adults in Collier County). Race was evenly distributed, with 84 percent of survey respondents being white (90% in the overall population in ), 7 percent of respondents were black (7% in the overall population) and 9 percent were other (3% in the overall population). The surveys were completed by a higher proportion of Hispanic residents than in the overall population (58% of the survey respondents identified as Hispanic vs. 27% in the overall population in ). Of those who responded to the survey, the majority (59.6%) reported having private health insurance, and 25.6 percent reported being uninsured. This compares to 2012 American Consumer Survey estimates of 55.8 percent of residents having private health insurance, and 20.6 percent having no health insurance. (Respondents were allowed to select multiple answers for the majority of the questions asked.) What type of insurance do you have?* private insurance (through employer) % private insurance (self-pay) % Medicare % Medicaid % Veteran 0 0.0% other** 6 2.7% none % *totals to more than 100% as some respondents selected multiple options **share of cost, Women's Health Foundation, Entegral, with supplemental coverage, Tricare 74

75 59 percent of survey respondents ages 18 to 34 reported having no health insurance. Of those ages 35 to 65, 38 percent reported having no health insurance. The findings of the surveys were compiled by the Health Planning Council, and are as follows: (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) When asked, How would you rate the general health of residents? 19 percent of survey respondents said Excellent, 51 percent said Good, 23 percent said Fair, and 8 percent said Poor. When asked, How would you rate the quality of healthcare in? 25 percent said Excellent, 51 percent said Good, 19 percent said Fair, and 6 percent said Poor. When asked where residents go to get health information, the majority of respondents noted that they go to their family doctor (193 responses) as well as friends or relatives (180 responses). When asked where they go to receive healthcare services, the majority said they visit their family doctor (147 responses) or an area clinic (132 responses). Those in the 18 to 34 age group reported a higher percentage of those who receive healthcare at an area clinic (60.5% of those ages 18 to 34 reported going to a clinic vs. 35.6% of total respondents). Survey respondents in the 35 to 65 age group more frequently responded that they see a family doctor for their healthcare needs (64.1% of those ages 35 to 65 reported going to a family doctor vs. 39.6% of total respondents). Of those who reported having no health insurance, 78.8 percent reported going to a clinic for healthcare. Where do you think the residents of Collier County go to get health information? Where do you go to get healthcare? family doctor 147 family doctor or health provider 193 clinic 132 friends or relatives 180 health department 36 Internet 140 hospital/emergency room 34 television 70 other* 17 newspaper 47 don't know 5 magazines 41 radio 39 books 35 other* 10 *insurance carrier, community events, seminars, wellness programs, emergency room, referrals *specialist, out of state, abroad, Internet, Family Care North, Women's Health Foundation, itech, alternative therapists, referrals, wellness, urgent care, Senior Friendship (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 75

76 Respondents were asked their opinions on healthcare difficulties for specific populations in Collier County. Of the population groups listed, those who are uninsured and have low income levels were selected most often (160 responses). The next most frequently chosen option was migrants (120 responses) and non-english speaking residents (99 responses). With regards to specific areas of the county where residents are thought to have a particularly difficult time accessing healthcare services, 123 respondents said there are none. 125 respondents named multiple locations in the area as having difficulty accessing health services. The areas with the most responses listed were Immokalee (51 responses), Golden Gate (32 responses), and East Naples (18 responses). What types of residents of have more difficulty with healthcare than others? Are there areas/neighborhoods where residents have a particularly difficult time accessing health services? uninsured/low-income 160 no 123 migrants 120 yes* 125 non-english speaking 99 adults 78 elderly/senior citizens 54 persons with disabilities 30 children 27 teens/adolescents 25 persons in dependency (foster care/no-relative care) 24 other* 9 veterans 8 none 7 *middle income, immigrants, substance abuse users, people on Medicaid, undocumented, unemployed, alternative therapy practitioners' clients *Immokalee, Golden Gate, East Naples, lowincome areas, Everglades City, farm worker village, Naples Manor, rural areas, Copeland, Naples Park, Naples, Granada Road, rural areas, The Trails, Marco Island, village area, Ave Maria (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 76

77 The surveys also asked about difficulties in receiving specific types of health services. Seventy-two respondents said, no, there are no services that individuals in have difficulty accessing. Of those who felt there were services that were difficult to access, dental care for adults was number one, with 118 responses. Next highest on the list was specialty care, with 66 responses and mental health care for adults (62 responses). *other: food stamps, 24-hour pharmacy, after-hours medical care, dietary counseling, doctors who accept Medicare and Medicaid, follow-up after hospital stay, domestic violence services for men (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 77

78 Possible options for improving the health of area residents were given. Financial assistance for health care was chosen most often by survey respondents, with 126 responses. The next highest options were job opportunities (88 responses) and health education (87 responses). *other: hospital in Immokalee, case management for persons with chronic illness and frequent emergency room visits, insurance options education, health services located closer to where people live, more providers who accept Medicaid and Medicare, alternative therapists, fire Allen Weiss and Kevin Cooper - people of Naples deserve a fair and honest hospital administration, affordable health insurance (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 78

79 Respondents were asked to select what they felt to be the three most important health concerns for residents of. Access to primary care topped the list, with 113 responses. Second highest on the list was obesity, with 84 responses, followed by access to specialty care (79 responses) and diabetes with 76 responses. *other: allergies, lack of affordable medical insurance and medical care, drug dependency, liver and kidney disease, access to nutrition information, lack of healthy lifestyle, lack of information on managed care aspect of Medicare replacement options, lack of Medicaid doctors, preventive medicine, crack down on doctors writing prescriptions for pain killers, system that does not include alternative therapies (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 79

80 Respondents were then asked to select the three most important risky behaviors in. Being overweight was listed most frequently, with 161 responses. Other risky behaviors identified included substance abuse (129 responses), distracted driving (88 responses), poor eating habits (77 responses), and smoking/tobacco use and lack of exercise, each with 76 responses. *other: people who cannot afford to take care of children either financially or emotionally should not have children, being poor, GMO wheat, chemicals in our water and food supply (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) 80

81 People sometimes delay receiving treatment for their ailments, which can lead to further problems and/or higher costs. Respondents were asked to identify the main reason that keeps residents from seeking medical treatment. A lack of health insurance and/or lack of ability to pay was cited most frequently (169 responses. The next most often cited reason for delaying treatment was transportation (109 responses), and lack of knowledge/understanding of need (54 responses). *other: lack of confidence in the level of healthcare available in the area, it takes all day (Please note that OTHER was listed as an option on most survey questions. Respondents filled in individual responses to specify what they meant by OTHER. The views expressed in these responses are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida.) Survey respondents were given the opportunity to offer additional comments on health and healthcare in. Some general themes to these comments were the need for more doctors and more services in the county, help for residents with affordability (healthcare as well as health insurance), and the need for more health education (in the schools and in the community at large). It was also mentioned frequently that is a very diverse community, and is difficult to assess as a whole. Certain parts of the county have fewer resources nearby, making it a need for there to be more services in the areas where they are lacking or for there to be more transportation options to get to the areas where resources are more abundant. A complete listing of the survey comments is included in Appendix E. 81

82 Interviews with Community Leaders Introduction The Health Planning Council of Southwest Florida (HPC) conducted twenty-two key informant interviews in late 2013 with the cooperation of the Healthcare Network of Southwest Florida. The purpose of conducting the interviews was to better understand the perspectives of key community leaders on the health and healthcare needs of residents. These interviews were intended to ascertain opinions among key individuals likely to be knowledgeable about the community and who are influential over the opinions of others about health concerns in the county. The findings provide qualitative information and reveal factors affecting the views and sentiments regarding healthcare services in. A summary of community leaders opinions is reported without judging the veracity of their comments. Methodology A community committee created by the Healthcare Network of Southwest Florida (HcN Community Health Assessment Group) compiled a list of possible interview subjects and made initial contact with the interviewees. The list included healthcare providers, healthcare consumers, and representatives of local businesses and community organizations. HPC staff conducted the interviews in person. The average interview lasted between thirty and sixty minutes. Twenty-two key community leaders were interviewed at the place of their employment or another location of their choosing in in August and September of The interviewees were told that none of their comments would be directly attributed to them but that a list of all participants would be included in this report. That list in included in Appendix G. All interviews were conducted using a standard questionnaire. The instrument used to conduct the interviews is included in Appendix F. Community leaders were asked to provide comments on the following issues: Overall perspective of healthcare in ; Perception of essential components of the county s healthcare system; Opinions of important health issues that affect county residents and the types of services needed to address these issues; Impressions of specific health services available in the county; Thoughts on helpful services that may be missing from the county; and Opinions on the parties responsible for initiating and addressing health issues for the county. 82

83 Interview Analysis The leaders interviewed were asked whether they serve on any boards or have any affiliations with healthcare providers in the community that deliver healthcare services that may have helped form their opinions. These affiliations included the Dental Association, PLAN board, Rural Health Network Advisory Board, Healthy Families Advisory Board, Avow Hospice Advisory Board, itech Nursing School Advisory Board, Healthy Children s Coalition, Leadership Coalition on Aging, and Integral Health Plan. The length of time that the community leaders have lived and/or worked in ranges from fourteen months to forty years. The average number of years that an interviewee has lived or worked in is eighteen years. The interview questions asked of each community leader were identical. The questions have been grouped into seven major categories. A summary of the leaders responses by each of the categories follows. There is some duplication of subject matter and feedback between the categories. Paraphrases are included to reflect some commonly held opinions and direct quotes are employed when appropriate. This section of the report summarizes what the community leaders said without assessing accuracy of their comments. General Perceptions When asked to share their impressions about health and healthcare in, community leaders spoke at length about the assets and deficiencies of the system. The majority of the respondents noted that there are many health services available in, but there are significant barriers to accessing these services. It was felt by many that, if you have insurance or money, services are readily available, but for those without, preventive services and regular care are difficult to access. Immokalee residents in particular were felt to have limited resources readily available, although one interviewee felt that there have been big improvements meeting unmet needs in the Immokalee area in recent years. The services that are available were felt by many to be of good quality. One respondent stated, In general has good health care, especially for people who are permanent residents or citizens of the county. Others said it was, quite good and excellent. Assessing the overall health of residents was difficult for many of the interviewees. The difficulty was attributed to the distinctly different types of residents across the county. Health is felt to be divided along economic lines. One interviewee explained, Those with money have healthy diets and access to quality health care. The poor do not have access to proper health care. Racial disparities were also noted. Overall, though, many interviewees responded favorably about the health of the community. I think it has to be pretty good. Sometimes people perceive our population as older and more infirmed. Not really the case, shared one interviewee. There is always a need for quality health information in communities. By far the number one source for health information in the county cited by the interviewees was word of mouth. The next most often 83

84 mentioned were the Internet, a family doctor, and the Marion E Fether clinic. Also cited were 2-1-1, the Health Department, emergency rooms, publications/books, the media, and the Neighborhood Health Clinic. Pressing Healthcare Needs The community leaders were asked to identify the most pressing healthcare needs in. The most common responses were affordable dental care (especially for adults) and access to primary care. Several interviewees suggested that substance abuse treatment, health education, and elder care were also pressing healthcare needs. In particular, it was stated frequently that there are not enough skilled nursing facility beds for seniors in. Other needs mentioned by interviewees included access to mental health care, more Medicaid doctors, specialty care, obesity prevention, access for minorities, accessible health care for veterans, affordable prescription drugs, education of what resources are available, transportation, preventive care, and affordable health insurance. Issues Affecting Specific Groups Community leaders were asked to give their opinion on issues impacting particular groups of Collier County residents. Those groups included children, teen/adolescents, adults, the elderly, the uninsured and Veterans. Seven community leaders suggested that obesity was the most pressing health issue for children, and similarly, six others suggested that nutrition was the most pressing issue. It was stated by one interviewee that, they eat a lot of fast food. Other issues cited were dental care, exercise, preventive care, specialty care, asthma, mental health services, vision care, immunizations, safety program, and substance abuse. One interviewee specifically noted that there are, Not many resources for children under five years old on Medicaid. Teens and adolescents present a different list of healthcare needs. It was widely stated that there is a need for further sex education. Several of the interviewed leaders stated that there is a need for a substance abuse prevention and treatment program for teens. One leader noted that, "According to Drug Free Collier study, more teens are smoking weed than tobacco," and another leader felt the issue was more with prescription drug abuse. Other issues mentioned included obesity, health information, mental health services, teen pregnancy, teen violence, STDs, preventive care, and nutrition. For adults, access to primary care and preventive care were the most often mentioned pressing health concerns. Chronic conditions, such as obesity and heart disease were listed by several interviewees as major health issues as well. Also noted were access to dental care, affordability, obesity, access to mental health care, prescription medications, health education, general surgery needs, gynecology, cancer, and nutrition. The elderly generally have access to care through Medicare and so are typically considered to be in a better situation than many others in the county. Of those who felt that the elderly do have pressing health issues, their number one concern was assistance for seniors in their own homes. Access to primary care, transportation, and a lack of nursing home beds were listed by several interviewees as pressing health concerns as well. Also mentioned were coordination of care, cardiovascular services, 84

85 prescription drug abuse, access to dental care, supportive services, urology, vision, domestic abuse, financial abuse, and pneumonia. It was mentioned by one community leader that there is a need for more lifestyle programs for the elderly. When discussing the uninsured in, the most common healthcare issue mentioned was access to primary care. One interviewee stated, Collier does a pretty good job with health care. The PLAN program is good. Undocumenteds, however, have no access except through the ER. Mentioned nearly as frequently as access to primary care for the uninsured, were the lack of local dental options for those without health insurance, as well as the large number of chronic conditions of this population. Interviewees were also concerned about affordable medications, preventive care, affordability of health care and health insurance, obesity, nutrition, access to mental health care, depression/anxiety, health education, not enough Medicaid doctors, immunizations, and access to specialty care. Similar to the elderly who have access to Medicare, Veterans are often felt to have fewer issues with health care as they have access to Veterans Assistance benefits. In fact, multiple leaders interviewed stated that Veterans in have good access to care. However, health issues that were mentioned included mental health care, distance to services/transportation, lack of a Veterans nursing home, difficulty navigating the VA system, access to primary care, access to dental care, and homelessness. Types of Residents with Difficulty Accessing Healthcare Interviewees were asked about types of residents who have particular difficulty accessing care. Multiple community leaders felt that undocumented residents and migrant residents have difficulty accessing care, often due to language and cultural barriers. Additionally, undocumented residents often do not know where they can go for care. Migrants were said by one interviewee to feel that they did not receive holistic care, but rather a patch them up and get them out approach. The next most frequently mentioned group was the poor. It was noted by one respondent, Low-income residents have trouble paying, have trouble with access, and have trouble even if they have Medicaid, as many physicians won t take it. Other groups specifically mentioned as having difficulty with accessing care in were the uninsured, Haitians, the elderly, Hispanic, the unemployed, homeless, and pregnant women. Impressions Regarding Services The leaders were asked to give their impressions about the availability of different types of healthcare services and any obstacles that residents encounter when attempting to receive those types of services. When asked where residents who have difficulty paying go to receive health care services, twelve leaders suggested the Neighborhood Health Clinic, and eleven mentioned the area emergency rooms. Multiple interviewees also stated that the Healthcare Network of Southwest Florida was an option for low-income residents, however, one interviewee stated that when potential patients hear that there is a sliding-fee scale they are often intimidated by the unknown of how high or low their bill might end up being and choose not to go. Other responses included the Health Department, that residents simply put off receiving care, Senior Friendship Center, PLAN, Catholic Charities, David Lawrence for mental health issues, Social Services, Women s Health Foundation, the United Way, Health and Human Services, 911, the Salvation Army, area churches, St. Matthew s, and private doctors. 85

86 There were mixed feelings regarding the availability of primary care in. Just over half of respondents felt that primary care is unavailable, particularly for those who are uninsured, underinsured, and/or have Medicaid. Just under half of respondents stated that primary care was available for the most part, but it can be costly and waits to get an appointment can be long, suggesting that more primary care providers would be helpful. Of the care available, most felt it was good quality. One leader stated, The quality of care is fine, but there isn t enough of it. The community leaders interviewed were divided on the availability of dental care in. One leader stated, I think there are plenty of dentists. Interviewees mentioned that there were dental services available at the NCEF Pediatric Dental Clinic, the Marion E Fether clinic and Senior Friendship Center. The Neighborhood Health Clinic was mentioned as another option, but only for already established medical patients for medically necessary dental issues. One interviewee stated, I think the Healthcare Network partnership has solved a huge part of kids dental care. An adult dental clinic would be huge. Others stated that affordable care was not available. One interviewee stated, Not enough at all. We have enough children s dental but not enough for adults. Another leader stated of dental care there is, tons of it if you have money, very little if not. One community leader felt that Immokalee residents did not have quite enough dental care options, stating, There is not a local dentist in private practice in Immokalee. At the clinic they only do extractions. Very, very limited to most people here. Another representative of Immokalee residents felt that, preventive care is not given. The quality of the available care was felt by the majority of leaders to be good. One interviewee mentioned recent improvements in the quality of dental care in, Healthcare Network has really brought it up in the last five years. Could use more funding to provide more services. Another stated (of the pediatric program), I ve heard many good things. Big numbers, big outcomes. Most of the community leaders stated that residents have a variety of options in the county for specialty care. One leader specifically noted, We have a phenomenal variety of specialists. For those who have the insurance and can afford to pay, the specialists are renowned. Residents without insurance were said to have long waits to get in, particularly during the snowbird season. Additionally, residents with Medicaid or Medicare often have difficulty finding specialty providers who will accept their insurance. The majority of community leaders felt the quality of the specialty care in is very good or good. Good if you have insurance, stated one interviewee. The majority of community leaders felt that mental health care is mostly unavailable in. David Lawrence was listed as a resource; but was felt by many to be lacking in the number of providers available to meet the need. One interviewee noted that there is no Spanish-speaking therapist at David Lawrence. In addition to David Lawrence, one interviewee stated that there was one private practice mental health practitioner in Immokalee, as well as social workers at the Neighborhood Health Clinic. Opinions of the quality of the available mental health services were mixed. Half had good things to say about the care available at David Lawrence. Very good. David Lawrence is very good; phenomenal. Good care at David Lawrence. Others felt the mental health care available in needs improvement. One leader stated, It is marginal at best for those without good insurance. 86

87 Substance abuse treatment was felt by most to be available in the county, but somewhat limited for those who cannot afford to pay. One community leader stated that it is, very expensive except David Lawrence with limited capacity. Besides David Lawrence, leaders mentioned Hazelden and The Willough at Naples as substance abuse care options in. It was noted that there is a need for more options for those without insurance or the ability to pay. It was also mentioned by multiple interviewees stated that prevention efforts need improved. One community leader noted that there is a, huge issue in prescription pain pills; mainly adults. The quality of substance abuse care in was felt by most community leaders to be good or very good. Some interviewees felt that the quality of services was less than optimal for those residents without good health insurance or the ability to pay. Suggestions for improvements in the county included prevention programs specifically for teens, and the addition of a detox center locally. Emergency care options in are available at the area hospitals as well as urgent care centers. Interviewees felt that emergency care in the county was very good here, and very good at NCH.: Others stated, good emergency response system, and, area EMS is excellent. The time of year a resident needs to use emergency services can make a difference, according to two interviewees. One stated, Our ERs are adequate most of the year. It is season* that we run into challenge. The other stated, During season it is crazy. Waiting for hours. It was also noted that there is no trauma center in Naples. (*Season refers to the winter months when the population swells with temporary and seasonal residents.) The level of hospital care in general (non-emergency) in was thought by most interviewees to be good. Comments included, good care, quality care, excellent, NCH is very good, and Physicians Regional is very good. A few respondents were not as positive, stating the following, There is a huge lack of individualization, It's not as good as everyone thinks, and understaffed and overworked, which leaves a lot of room for error. It was noted by multiple interviewees that lower income residents were moved out faster than those with good health insurance. It was also stated by one interviewee that area hospitals often aren t fully admitting patients; keeping them in observation, which leads to the insurance company refusing to pay for the charges. Resources for hospice care in were felt to be available, albeit somewhat underutilized, possibly due to physicians not referring early enough and often enough. The quality was felt to be good overall. One interviewee stated that there are, a number of hospice operations; all of them do good jobs. Another was pleased to note that, They are terrific about doing things on an individual level. Pediatric care was felt by most respondents to be widely available, except for certain pediatric specialties. The quality was considered good overall, although children on Medicaid were thought to have long waits to get an appointment. Neonatal care was felt by one community leader to be available and excellent at NCH North Naples, although another community leader stated, For neonatal care, I hear that all go to Healthpark. According to the interviewed leaders, pediatric specialties and neonatal care are the services most often requiring residents to be referred outside the county. Also mentioned frequently was advanced cancer treatment. Other services that were difficult to find in were a trauma center, dental 87

88 services, vision service, a high risk obstetrics clinic, substance abuse detox, disease support groups, heart issues, transplants, clinical trials, epilepsy services, and care for severe burns. It is generally believed that the residents of the areas outside of Naples often have greater difficulty accessing health services. The neighborhoods mentioned most frequently as having difficulty accessing services were Immokalee and Golden Gate. Also mentioned were East Naples, Everglades City, Northeast, Eastern, rural areas, Naples Manor, North Naples, Ochopee, and Chokoloskee. Transportation is seen as a major barrier to care for many of these areas. While most interviewees mentioned the local CAT bus as an option that has been helpful to many residents, several leaders felt that the limited routes and schedules were not sufficient for the needs of the entire county. With regards to low-income Immokalee residents in particular, one community leader stated, Anything referred outside of Immokalee takes all day on CAT bus. Some people just don t go, rather than take an entire day off work. It was stated by at least one leader, however, that Immokalee has been well served by satellite offices and mobile health services. Good Wheels was also mentioned as an option for Medicaid clients, but there are limitations, particularly for parents of several young children only the parent and child may use Good Wheels, which leaves the parent with the added task of finding childcare for the other children at home. Affordable Care Act/Healthcare Reform Interviewees were asked their thoughts on how the Affordable Care Act will affect healthcare in Collier County, and how best to educate the public about the upcoming changes. Some community leaders had positive feelings regarding the Affordable Care Act. Some suggested that more residents will have health insurance, which could lead to more residents taking advantage of preventive care. Some community leaders speculated that there would not be enough local providers once the Affordable Care Act has been implemented. Two interviewees felt that the Affordable Care Act would cause an increase in premiums and/or co-pays, while one interviewee felt that premiums would go down. Educating the population of about the upcoming changes may require multiple avenues. Suggestions primarily included using the media as well as pamphlets and flyers at area doctors offices. It was suggested that information be made available via the Internet: websites and social media, as well as one-on-one. Other suggestions included going through area employers, festivals, having a resource hotline, having information available at faith-based organizations, having forums, seminars, direct mailings, and promoting information at local schools. While pamphlets, flyers, and brochures are often thought of as effective ways to widely spread information, multiple community leaders suggested that the illiteracy rate in the county is too high for written material to be very effective. One leader felt strongly that promotores (lay Hispanic/Latino community members who promote health in their own communities by providing basic health education) would be beneficial for spreading health information. 88

89 Most Important Health Issue and How to Address It The number one health issue identified by most of the interviewed community leaders in is access to care. Some interviewees felt access to care was particularly difficult for low-income residents and the uninsured, and one interviewee felt that Veterans also had difficulty accessing care. Several interviewees also felt that prevention and management of chronic illnesses are a top concern for residents. Other issues mentioned were access to dental care (primarily for adults), help for seniors, a need for more primary care providers, affordability, coordination of care, outreach and substance abuse. A variety of ideas on how to implement change regarding these health issues in were mentioned. It was suggested by some community leaders that the government needs to place more healthcare providers in the area, and that the agencies that are already in should work together to offer more outreach, health education, and prevention services. It was suggested by one community leader that residents need to take more personal responsibility for their health as well. It was mentioned by multiple community leaders that has a great need for more skilled nursing facility beds, particularly those for Medicaid and Medicare patients. These beds fill up quickly, leaving many seniors without any options for them in. Additional comments from community leaders on health and health care in included: It s pretty darn good here. I would like to see universal health care for everybody in the country. I think that Obama health care is a step in the right direction. Everything is very piecemeal at this point. There are many resources, but the knowledge isn t there. 89

90 Appendix A HcN Community Health Assessment Group Members Colleen Cornwall Able Academy Gregory Preston Integral Quality Care Barry Williams Parks & Recreation Becky Kokkinos Legislative Aid Vicki Carr Rural Health Network April Donahue Medical Society Joan Colfer Susan Craig Taylor Hamilton Physician Regional Nancy Frees Florida Department of Health, Tijuanna Clemons RCMA Lou Traina Healthcare Network Foundation Burt Saunders Representative State Senator Haris Domond Mike Ellis Todd Foege Paul Midney Tami Raznoff Sandra Steele Sheila Jackson Assistant to Matt Hudson, State Representative Jim Warnken United Way of Kaydee Tuff Healthcare Network of Southwest Florida Dr. Lauren Governale University of Florida Dental NCEF Pediatric Dental Center Carol Conway Tammy DeCaro Araceli Gomez Sallie Williams Williams Consulting Group Hope Hospice Thomas Van Pelt Women s Health Foundation 90

91 Appendix B County Health Rankings Definitions for each measure are listed on the next pages. Collier County Error Margin Florida National Benchmark* Health Outcomes 3 Mortality 1 Premature death 5,876 5,527-6,225 7,310 5,317 Morbidity 4 Poor or fair health 16% 13-19% 16% 10% Poor physical health days Poor mental health days Low birth weight 7.0% % 8.7% 6.0% Health Factors 10 Health Behaviors 5 Adult smoking 16% 14-19% 19% 13% Adult obesity 21% 19-24% 26% 25% Physical inactivity 17% 15-20% 24% 21% Excessive drinking 17% 14-19% 16% 7% Motor vehicle crash death rate Sexually transmitted infections Teen birth rate Clinical Care 17 Uninsured 30% 28-31% 25% 11% Primary care physicians** 1,474:1 1,439:1 1,067:1 Dentists** 1,860:1 2,095:1 1,516:1 Preventable hospital stays Diabetic screening 86% 83-88% 84% 90% Mammography screening 78% 75-81% 70% 73% Social & Economic Factors 30 High school graduation** 73% 71% Some college 48% 45-51% 59% 70% Unemployment 10.3% 10.5% 5.0% Children in poverty 31% 26-35% 25% 14% Inadequate social support 20% 16-23% 22% 14% Children in single-parent households 32% 29-35% 37% 20% Violent crime rate Rank (of 67) 91

92 Physical Environment 5 Daily fine particulate matter Drinking water safety 10% 3% 0% Access to recreational facilities Limited access to healthy foods** 8% 7% 1% Fast food restaurants 32% 44% 27% Source: County Health Rankings & Roadmaps. Available at Accessed July 1, *90th percentile, i.e., only 10% are better **Data should not be compared with prior years due to changes in definition. Note: Blank values reflect unreliable or missing data. Definitions of Health Measures Premature death - Years of potential life lost before age 75 per 100,000 population (age-adjusted) Poor or fair health - Percent of adults reporting fair or poor health (age-adjusted) Poor physical health days Average number of physically unhealthy days reported in past 30 days (age-adjusted) Poor mental health days - Average number of mentally unhealthy days reported in past 30 days (age-adjusted) Low birth weight - Percent of live births with low birth weight (<2500 grams) Adult smoking - Percent of adults that report smoking >=100 cigarettes and currently smoking Adult obesity - Percent of adults that report a BMI >=30 Physical inactivity - Percent of adults aged 20 and over reporting no leisure time physical activity Excessive drinking - Binge plus heavy drinking Motor vehicle crash death rate - Motor vehicle crash deaths per 100,000 population Sexually transmitted infections - Chlamydia rate per 100,000 population Teen birth rate - Teen birth rate per 1,000 female population, ages Uninsured - Percent of population under age 65 without health insurance Primary care physicians - Ratio of population to primary care physicians Dentists - Ratio of population to dentists Preventable hospital stays - Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees Diabetic screening - Percent of diabetic Medicare enrollees that receive HbA1c screening Mammography screening - Percent of female Medicare enrollees that receive mammography screening High school graduation - Percent of ninth grade cohort that graduates in 4 years Some college - Percent of adults aged years with some post-secondary education Unemployment - Percent of population age 16+ unemployed but seeking work Children in poverty - Percent of children under age 18 in poverty Inadequate social support - Percent of adults without social/emotional support Children in single-parent households - Percent of children that live in household headed by single parent Violent crime rate - Violent crime rate per 100,000 population Daily fine particulate matter - The average daily measure of fine particulate matter in micrograms per cubic meter (PM2.5) in a county Drinking water safety - Percentage of population exposed to water exceeding a violation limit during the past year Access to recreational facilities - Rate of recreational facilities per 100,000 population Limited access to healthy foods - Percent of population who are low-income and do not live close to a grocery store Fast food restaurants - Percent of all restaurants that are fast-food establishments 92

93 Appendix C Behavioral Risk Factor Surveillance Survey The Centers for Disease Control and Prevention began the Behavior Risk Factor Surveillance Survey (BRFSS) in the early 1980s in a handful of states. Today, all states participate in the survey. The 2010 Florida BRFSS provides individual counties and the state with a rich data source to estimate the prevalence of personal health behaviors that contribute to mortality and morbidity among adults. Over 35,000 interviews were completed in the 2010 calendar year, with a target sample size of 500 completed surveys in each county. The 2010 BRFSS is the third time the survey was conducted at county-level. Previous county-level surveys were conducted in 2002 and residents completed the survey in County 2010 State 2010 County 2007 Percent Quartile* Percent Percent Alcohol Consumption Adults who engage in heavy or binge drinking. 19.2% % 16.1% ( ) ( ) ( ) Arthritis Adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 0.2% ( ) 14.9% ( ) 11.6% ( ) Adults who have been told they have some form of arthritis. 31.6% 32.0% 25.2% ( ) ( ) ( ) Asthma Adults who currently have asthma. 8.0% 2 8.3% 5.4% ( ) ( ) ( ) Cancer Screening Adults 50 years of age and older who received a blood stool test in the past year. 12.5% ( ) % ( ) 20.3% ( ) Adults 50 years of age and older who received a sigmoidoscopy or colonoscopy in the past five years. 56.3% ( ) % ( ) 61.0% ( ) Adults ages 50 years and older who have ever had a blood stool test. 41.5% ( ) % ( ) 49.0% ( ) Adults ages 50 years and older who have ever had a sigmoidoscopy or colonoscopy. 69.1% ( ) % ( ) 71.8% ( ) Men 45 years of age and older who have been told they have prostate cancer. 12.9% ( ) 4 7.3% ( ) Men ages 50 years and older who have ever had a digital rectal exam. 84.9% ( ) % ( ) 86.6% ( ) 93

94 Men ages 50 years and older who have ever had a PSA test. 85.4% % 85.0% ( ) ( ) ( ) Women 18 years of age and older who received a Pap test in the past year. 54.1% ( ) % ( ) 62.9% ( ) Women 40 years of age and older who received a mammogram in the past year. 69.3% ( ) % ( ) 64.7% ( ) Women ages 40 years and older who had a clinical breast exam in the past year. 69.5% ( ) % ( ) 64.0% ( ) Women who have had a hysterectomy. 29.1% % ( ) ( ) Cardiovascular Disease Adults who have ever had a heart attack, angina, or coronary heart disease. 12.1% ( ) % ( ) 10.2% ( ) Adults who have ever had a stroke. 4.1% 3 3.5% 4.1% ( ) ( ) ( ) Cholesterol Awareness Adults who have diagnosed high blood cholesterol. 41.4% 38.6% 36.2% ( ) ( ) ( ) Dental Care Adults who had a permanent tooth removed because of tooth decay or gum disease. 48.4% ( ) % ( ) Adults who had their teeth cleaned in the past year. 69.2% % ( ) ( ) Adults who visited a dentist of dental clinic in the past year. 73.3% % ( ) ( ) Diabetes Adults with diabetes who ever had diabetes self-management education. 58.2% ( ) % ( ) 75.0% ( ) Adults with diabetes who had an annual eye exam. 62.4% % 77.6% ( ) ( ) ( ) Adults with diabetes who had an annual foot exam. 57.5% % 63.1% ( ) ( ) ( ) Adults with diabetes who had two A1C tests in the past year. 71.0% % 54.4% ( ) ( ) ( ) Adults with diagnosed diabetes. 9.4% % 8.8% ( ) ( ) ( ) Disability 94

95 Adults who are limited in any way in any activities because of physical, mental, or emotional problems. 19.3% ( ) % ( ) 18.4% ( ) Adults who use special equipment because of a health problem. 8.2% ( ) 1 9.3% ( ) 7.7% ( ) Family Planning Females less than 45 years old or males less than 60 years old who report that they or their partner take measures to prevent pregnancy. 54.9% ( ) 56.2% ( ) Health Care Access & Coverage Adults who could not see a doctor at least once in the past year due to cost. 14.5% ( ) % ( ) 13.0% ( ) Adults who had a medical checkup in the past year. 73.1% % 74.5% ( ) ( ) ( ) Adults who have a personal doctor. 80.2% % 68.8% ( ) ( ) ( ) Adults who think they would get better medical care if they belonged to a different race/ethnic group. 8.7% ( ) 10.8% ( ) Adults with any type of health care insurance coverage. 82.7% % 77.8% ( ) ( ) ( ) Health Status & Quality of Life Adults who always or usually receive the social and emotional support they need. 80.3% ( ) % ( ) 82.8% ( ) Adults who had poor mental health on 14 or more of the past 30 days. 17.2% ( ) % ( ) 10.1% ( ) Adults who had poor physical health on 14 or more of the past 30 days. 11.0% ( ) % ( ) 11.8% ( ) Adults who said their overall health was "fair" or "poor". 18.8% % 15.5% ( ) ( ) ( ) Adults whose poor physical or mental health kept them from doing usual activities on 14 or more of the past 30 days. 17.8% ( ) % ( ) 14.6% ( ) Adults with good mental health. 82.8% % 89.9% ( ) ( ) ( ) Adults with good physical health. 89.0% % 88.2% ( ) ( ) ( ) Adults with good to excellent overall health. 81.2% % 84.5% ( ) ( ) ( ) 95

96 Average number of days where poor mental or physical health interfered with activities of daily living in the past 30 days. 4.9% ( ) 1 5.2% ( ) 4.4% ( ) HIV/AIDS Adults less than 65 years of age who had an HIV test in the past 12 months. 1.8% ( ) 4 7.0% ( ) 16.1% ( ) Adults less than 65 years of age who have ever been tested for HIV. 34.0% ( ) % ( ) 38.2% ( ) Hypertension Awareness & Control Adults with diagnosed hypertension. 30.9% % 29.8% ( ) ( ) ( ) Adults with hypertension who currently take high blood pressure medicine. 76.9% ( ) 82.8% ( ) 77.1% ( ) Immunization Adults age 65 and older who have ever received a pneumonia vaccination. 80.7% ( ) % ( ) 71.9% ( ) Adults age 65 and older who received a flu shot in the past year. 74.8% ( ) % ( ) 74.8% ( ) Adults who have ever received a pneumonia vaccination. 41.6% % 35.2% ( ) ( ) ( ) Adults who received a flu shot in the past year. 47.9% % 41.0% ( ) ( ) ( ) Injury Prevention Adults 45 older who had a fall-related injury in the past 3 months. 3.5% ( ) 1 5.7% ( ) Adults who "always" or "nearly always" used seat belts when driving or riding in a car. 97.4% ( ) % ( ) Adults who, in the past 30 days, drove a vehicle after consuming too many alcoholic beverages. 1.0% ( ) 1.9% ( ) Overweight & Obesity Adults who are obese. 22.4% % 22.0% ( ) ( ) ( ) Adults who are overweight. 35.5% % 37.5% ( ) ( ) ( ) Adults who are overweight or obese. 57.9% % 59.6% ( ) ( ) ( ) Adults who have a healthy weight (BMI from 18.5 to 24.9). 39.3% % 38.3% 96

97 ( ) ( ) ( ) Tobacco Use & Exposure Adult current smokers who tried to quit smoking at least once in the past year. 49.8% ( ) % ( ) 43.0% ( ) Adults who are current smokers. 16.7% % 17.4% ( ) ( ) ( ) Adults who are former smokers. 37.3% % 33.3% ( ) ( ) ( ) Adults who have never smoked. 46.1% % 49.3% ( ) ( ) ( ) Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2010]. *County compared to other Florida Counties. In this instance, the lowest Quartile (4) equals the worst number. Approximately 500 adults were surveyed in each county in the years 2007 and Blanks in the quartile column indicate that not enough data was available to compute a quartile. Not all indicators have data for both 2007 and Confidence Intervals - Ranges in parentheses below the prevalence estimate represent the 95% confidence interval for the measure. 97

98 Appendix D Survey on Health and Healthcare in 1. How would you rate the general health of residents? Excellent Good Fair Poor 2. How would you rate the quality of healthcare in? Excellent Good Fair Poor 3. Where do you think the residents of go to get health information (select all that apply)? Books Magazines Family doctor or health provider Newspaper Friends or relatives Radio Internet Television Other 4. Where do you go to get healthcare (select all that apply)? Clinic Health department Family doctor Hospital/emergency room Don't know Other 5. Which of the following do you feel are the three most important health concerns in (select three)? Access to primary care (family doctor) Access to specialty care (doctors who provide care for one specific medical issue) Aging problems (arthritis, hearing or vision loss, etc.) Asthma Cancer Crime Dental problems Diabetes Domestic violence Flu Heart disease and stroke Other HIV/AIDS Lack of food Mental health problems Not enough doctors Obesity Poor nutrition Senior care Sexually transmitted diseases (STDs) Teenage pregnancy Unsafe living conditions Unsafe work environment Women's issues 98

99 6. Which of the following do you feel are the three most important risky behaviors in (select three)? Being overweight Not using seat belts/child safety seats Discrimination Poor eating habits Distracted driving (texting, etc.) Smoking/tobacco use Dropping out of school Substance abuse (drug, alcohol, prescription, other) Lack of exercise Not getting shots to prevent disease Lack of maternity care Unsafe sex Not using birth control Other 7. What do you think is the main reason that keeps people in from seeking medical treatment? Cultural/health beliefs Fear (due to immigration status) Fear (not ready to face health problem) Health services too far away Lack of knowledge/understanding of need Lack of insurance/unable to pay for doctor's visit Language barrier No appointments available at doctor when needed/have to wait too long at doctor s office Transportation None/no barriers Other 8. What types of residents of have more difficulty with healthcare than others? Adults Children Elderly/senior citizens Migrants Non-English speaking None Persons in dependency (foster care/non-relative care) Persons with disabilities Teens/adolescents Uninsured/low-income Veterans Other 9. Are there areas/neighborhoods in the county where residents have a particularly difficult time accessing health services? No Yes If yes, which areas/neighborhoods? 99

100 10. Are there services that individuals in have difficulty accessing? No Yes If yes, which of the following services have you or someone you know had difficulty accessing (select all that apply)? Dental care (for adults) Mental health care (for adults) Dental care (for children) Mental health care (for children) Emergency care Pediatric care Hospital care Primary Care Maternity/prenatal care Specialty care Medications/pharmacy Other 11. What does need to improve the health of your family, friends, and neighbors? Additional health services Mental health services After-school/out-of-school programs More doctors Bicycle paths/walking paths Recreational facilities (parks, sports fields, etc.) Counseling & support groups Safer environment Financial assistance for health care Specialty doctors Health education Substance abuse treatment services Healthier food choices Transportation Job opportunities Wellness programs Other 12. Please share any additional comments you have about healthcare needs in. What is your Zip Code? Are you a permanent, seasonal, or temporary resident of? Permanent Seasonal Temporary Age: Under over 65 Gender: Male Female 100

101 Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Mixed Ethnicity: Hispanic or Latino Not Hispanic or Latino What is your primary language? English Spanish Creole Other What type of insurance do you have? Private insurance (through employer) Private insurance (self-pay) Veteran Medicare Medicaid None Other 101

102 Appendix E Survey on Health and Healthcare: Additional Comments* *Listed below are comments added by residents who completed the Survey on Health and Healthcare for. The views expressed in comments here are those of the comment writers alone. They do not represent the views or opinions of the Health Planning Council of Southwest Florida, nor do they represent the views or opinions of the Healthcare Network of Southwest Florida. The few facilities we have, the service is below average. Immokalee Clinic has confidentiality issues. Staff has poor behavior, lack of respect to clients, and their appearance (hickeys on neck) looks disgusting. Staff gossiping while patients wait for extensive periods of time. needs more availability to prevent obesity, specialists & emergency care. There is a need for an accurate representation of the diversity of our community among the boards and task forces that design and implement health care services for our citizens in Collier County. Health education in general. Most residents don't know that they can get health care here at the Gov't center. More services. I am from Illinois & I feel that they were more aware of patients. The health service is expensive when people do not have stable income. It is hard for people to get services for this reason. I know there are clinics that see people with no insurance, but they charge a lot of money; it will be good that all the clinics have the same rate for low income people, or the low income clinics have more offices in. Please help people to get educated about programs that we have in Collier. Poor information to the uninsured people and the Hispanic population is a big problem. More financial assistance for uninsured people going to specialty doctors, radiology, labs, supplies and medications. Collier needs more OBGYN for women that accept Medicaid. I think that RN's should go around middle schools at least twice a year and speak to kids about staying protected and making wise decisions and thinking before acting There are a lot of residents that have no employment and no Medicaid, but are relying on their SSI and SSA for and Medical Care More of the needs that I see are more in the eastern half of the county There needs to be more physicians and specialists that are willing to accept Medicaid patients in. A lot of children are in need of treatment but don't have transportation or a doctor who will accept their insurance. 102

103 Need more local specialist to accept Medicaid. I would like to see more specialty care. Need more doctors to be seed and putting a birthplace here. More specialists office to be close by. Better and fresh food in the schools and daycares. Nutritional Classes for parents and the consequences to eat fast food and junk food every day. Getting people into all the facilities we do have in. How do we get information to the people and when to get them to go to the proper agency? With the current number of homeless, unemployed and poorly nourished adults and children, basic needs are the most critical before there are obvious healthcare gaps except for those who are chronically ill. Because of the sheer size and diversity of Collier it's hard to provide a standard answer that represents the whole county. There should be more health/wellness and nutrition education programs in schools provided for children of in Collier County. Spoke with my family doctor once about healthier eating. Told him what the Wellness lady told me vs. what the Food and Nutrition Program lady told me. Doctor said to go with what the Food and Nutrition lady said to do. Which proved to me community needs access to more correct information from FNP people. Diverse population in terms of economic status so can't lump all residents with answers to questions. In the Immokalee area there is limited resources and most lack transportation or interpreter. needs to focus on adding additional healthcare resources to the residents in Immokalee. They should think about putting a hospital out here that can provide healthcare to more people. Transportation to Naples, Lehigh, or Fort Myers is a big issue. The issues vary by age and socioeconomic variables. This survey is too broad in many respects as many questions don't distinguish by age and socioeconomic variables. I feel there should be more OB/GYN offices that offer sliding fee discounts for self-pay patients in. Emergency rooms appear to be overused. The representative from the new 411 program was so proud, but when we started to talk, she realized that most of the programs on her list are very restricted. There is NO low-cost dental service for adults or seniors. Many programs are based in Immokalee. I had her list and she was appalled at the info I learned; the things that kept me from getting health care like not having children under age 18. The doctors at Senior Friendship do their best, but are so old; I am constantly concerned for their well-being. Knowing I'm there due to lack of income, one doctor wrote a blood pressure description that cost $149 a month! There are massive gaps in care that should really be examined. You need a much more detailed survey to get to the crux of these matters. 103

104 Doctors in only want to deal with rich people, and only want concierge service, and they do not deal with Medicare or Medicaid. Get NCH to allow more hospitals They want to control the health industry There is a wide range from very rich to very poor in. I think your survey is too general. More doctors. Seems like there are many affordable services available for families who are facing life changing issues with adolescents in Naples. I have done searches on the Internet and have found different support groups, free assessments. Unfortunately there are nowhere to the same services out in Immokalee or outlying areas. In the time I've lived in Immokalee I have come across many parents who want help but unfortunately feel that it is out of reach for them due to cost and distance. I am very concerned that the top rated department at NCH was kicked out after over 35 years of dedicated service. I refer to the radiologists. Naples Radiologists are hands down the best radiologists in Naples. The middle class need more options. Those who work do not qualify for Medicaid, and private insurance is costly. We need affordable health insurance that covers adults. A lot of the people that enter the country are very short of knowledge. I think it would be very helpful if they provide pamphlets explaining. Every day it is improving. Please help people who don't have medical insurance. Doctors shouldn't take advantage of people's lack of knowledge. In Immokalee, we need more doctors and nurses that are kind to all patients, without discrimination. In Immokalee there is a huge lack of services, such as for women. Immokalee needs more services, better quality services, and more transportation. In Immokalee there is a huge lack of doctors and specialists, and dentists for adults. The sidewalks are a disaster in Immokalee - not safe. We need more dentists and more opportunities. There is nothing for women. Immokalee lacks transportation. Need English language classes throughout the week for the elderly that are free. I think that you should implement more programs in the schools for children of all ages about nutrition, health and wellness. They need to be more doctors who help patients with limited resources. There are many patients who do not have money to pay for consultations with specialists then their disease progresses and their health is complicated. 104

105 Appendix F Health Assessment Key Informant Interview Guide On behalf of the Healthcare Network of Southwest Florida, the Health Planning Council of Southwest Florida is conducting a county-wide health assessment. The goal of this assessment is to identify the most pressing health needs of residents of including issues like access to health care, barriers to receiving healthcare and the most pressing health issues of residents. As a part of this study, we are conducting a series of interviews with key individuals throughout the county who have knowledge of the health needs of individuals in. You have been identified by the project team as a key informant based on your knowledge of the health-related issues for residents. This interview will take approximately 45 minutes. In the final report, the information you give will not be attributed to you by name. You will however be listed as a participant in the study. Some of the questions will be duplicative of material we have already discussed in earlier questions but they may prompt you to think of additional issues. Are you ready to get started? 1. Could you briefly describe your position and how long you have lived and/or worked in Collier County? 2. It is important that we understand any affiliations you have with healthcare providers in the community that may have helped form your opinions about these issues. Do you serve on any boards or participate in any organization that delivers healthcare services? 3. Please comment on your overall perspective on healthcare in including the services available to meet healthcare needs of residents. 4. Please comment on your overall perspective on the general health of residents. 5. Where do you think the residents of go to get needed health information? 6. What do you think are the most pressing healthcare needs in? 105

106 7. Now I am going to name some specific populations in and I would like you to comment about what you think are the most important health issues affecting them: a. Children b. Teens/adolescents c. Adults d. Elderly e. Uninsured f. Veterans 8. What types of residents of have more difficulty with healthcare than others? What are these difficulties? Why do you believe these folks have more difficulties with healthcare? What actions are necessary to address this issue? 9. Do you know where residents who have difficulty paying go to receive services? 10. What do you think are the essential components of a quality healthcare system for a community like? Are these components currently in? 11. I am going to name some specific types of services and ask you to share any impressions you have about them, particularly anything you know about how these services are available to all persons in and whether there are any obstacles to receiving these types of services: a. Primary care b. Dental care c. Specialty care d. Mental Health care e. Substance Abuse treatment f. Emergency care g. Hospital care h. Hospice care i. Pediatric/Neonatal Care 106

107 12. Are there other types of services that individuals in have difficulty accessing? 13. Are there services that individuals in must go outside of the county to receive? 14. Are there areas/neighborhoods in the County where residents have a particularly difficult time accessing services? 15. We often hear that transportation is an issue that impacts accessing needed health care. Is this something that you have seen in the community? 16. How do you think the healthcare reform will affect healthcare in? 17. Do you think healthcare reform will affect you personally? 18. What do you think are the best ways to educate people about the upcoming changes (regarding healthcare reform)? 19. Of all the issues and services we have discussed, which do you think is the most important health care issue? 20. What actions are necessary to address this issue? Who do you think should take responsibility for addressing this issue? 21. Do you have any additional comments you would like to share about health care needs in Collier County? 107

108 Appendix G Community Leaders Interviewed Tijuanna Clemmons RCMA Cathy Timuta Healthy Start Dr. Joan Colfer Nancy Frees Florida Department of Health, Mike Ellis Healthcare Network of Southwest Florida Dorin Oxender Lana Woods itech Michelle Jay PLAN Sallie Williams The Williams Consulting Group LLC Dr. Lauren Governale Chance Powell NCEF Pediatric Dental Barry Williams Parks & Recreation Lucy Ortiz The Shelter for Abused Women and Children Leslie Lascheid Neighborhood Health Clinic Armando Galella Catholic Charities of Heather Burton Hazelden Dave Schimmel David Lawrence Center Laurie Andrea Small business owner Julia Perkins Coalition of Immokalee Workers Barbara Miller Burzynski Elder Law Tammy DeCaro Hope HCS Rosa Kissane Doctor s Choice Home Care 108

109 Appendix H Definitions of Prevention Quality Indicators PQI-1 (Diabetes short-term complication): All non-maternal/non-neonatal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for short-term complications (ketoacidosis, hyperosmolarity, coma) PQI-3 (Diabetes long-term complication): Discharges age 18 years and older with ICD-9-CM principal diagnosis code for long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified) PQI-5 (Chronic obstructive pulmonary disease): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for COPD. PQI-7 (Hypertension): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for hypertension. PQI-8 (Congestive heart failure): All non-maternal/non-neonatal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for CHF. PQI-10 (Dehydration): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for hypovolemia. PQI-11 (Bacterial pneumonia): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for bacterial pneumonia. PQI-12 (Urinary tract infection): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code of urinary tract infection. PQI-13 (Angina admission without procedure): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for angina. PQI-14 (Uncontrolled diabetes): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for uncontrolled diabetes, without mention of a short-term or long-term complication. PQI-15 (Adult asthma): All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code of asthma. PQI-16 (Rate of lower-extremity amputation among patients with diabetes): All non-maternal discharges of age 18 years and older with ICD-9-CM procedure code for lower-extremity amputation in any field and diagnosis code of diabetes in any field. 109

110 Appendix I Florida Youth Substance Abuse Survey Percentages of youth and Florida Statewide youth who reported having used various drugs in the past 30 days, 2012 Past-30-day trend in alcohol, tobacco and other drug use for youth 2002, 2004, 2006, 2008, 2010 and