CNY DSRIP Collaborative Needs Assessment. Cayuga County. October Preliminary Needs Assessment Report Page 1

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1 CNY DSRIP Collaborative Needs Assessment Cayuga County October 2014 Preliminary Needs Assessment Report Page 1

2 Table of Contents Cayuga County...1 The Cayuga County Population...1 Overview of County Population Health...2 Utilization Indicators and Health Outcomes among County Medicaid Members...5 Cayuga County Health Care and Community Resources Key Health/Health Care Challenges Key Underlying Challenges in Cayuga County Comparison to Past Needs Assessments Preliminary Needs Assessment Report

3 Cayuga County Cayuga County is a long and narrow county that stretches nearly sixty-five miles and has plentiful water resources. Its population and services are concentrated around the county seat, Auburn, located in the central portion of the county. Cayuga County has one hospital, 2 Federally Qualified Health Centers (FQHC), and one FQHC look-alike that provide services to the county. The Cayuga County Population The population of Cayuga County is 79,996. Thirty-four percent (27, 381) of the county s population reside in Auburn, located 30 miles west of Syracuse. Cayuga County is not racially or ethnically diverse with 92.6% of the population reporting they are white. Auburn is slightly more racially diverse with 86.3% white, 8.5% black and 5.3% Asian. According to a Key Informant Interview, Cayuga is seeing an increase in the number and percentage of persons 65 years and older, with the younger cohorts decreasing. The number of individuals living in poverty and lowincome is higher in Cayuga County compare to Upstate New York, with the highest concentration of low-income residents in northern Cayuga. Eighteen percent of the population of Cayuga County is on Medicaid. Table 1 details the demographics of the City of Auburn and Cayuga County compared to Upstate New York (Upstate NY) and New York State (NY State). Five zip codes, including Auburn, within Caygua County (from census zip code tabulation areas ZCTA) are highlighted as within in the worst quartiles for percent of their residents living below 138 percent of the Federal poverty level (FPL): 13021, 13092, 13111, 13140, and Preliminary Needs Assessment Report Page 1

4 Table 1: Demographic, Socio-Economic, and Insurance Information Auburn Cayuga Upstate New York 1 New York State Total population size 27,381 79,996 11,198,904 19,398,125 Gender Male 51% 51% 49.1% 48.4% Female 49% 49% 50.9% 51.6% Race/Ethnicity White 86.3% 92.6% 81.8% 66% Black 8.5% 4.3% 8.7% 15.7% Asian 5.3% 0.6% 3.5% 7.5% American Indian/Alaska Native 0.4% 0.4% 0.3% 0.3% (AI/AN) Hispanic 3.6% 2.4% 9.7% 17.7% Foreign-born population 3.3% 2.4% 11.1% 22% Education Less than high school education 17.7% 14.4% 11.1% 15.1% Employment and Income Median household income $38,321 $50,950 $54,125 a $57,683 Unemployed 10.6% 8.2% 7.7% 8.7% In poverty (below 100% FPL) 18.4% 12.2% 11.2% 14.9% Below 138% FPL 18.5% 16.6% 21.5% Below 200% 30.9% 25.7% 31.6% 200% FPL-400% FPL 35.9% 29% 27.9% Above 400% FPL 33.2% 45.3% 40.5% Insurance Uninsured 11.2% 10.8% 9.1% 11.3% Medicaid 18.0% 14.9% 20.9% Urban/Rural Urban 100% 44.2% 79% 87.9% Rural 0% 55.8% 21% 12.1% Data source: American Community Survey, 5-Year Estimate a Average of median household incomes in Upstate New York counties. Overview of County Population Health This section includes a comprehensive collection of quantitative data. The quantitative data is then used as a foundation for qualitative findings, to identify a key health challenges. Leading Causes of Death and Hospitalizations Table 2 presents the leading causes of premature death. The top five causes of premature death are cancer, heart disease, unintentional injury, CLRD and diabetes. All five causes of premature death for residents of Cayuga County have rates higher than Upstate NY. Table 3 presents the leading causes of hospitalizations. Seven of the eight top leading causes of hospitalizations include rates higher than Upstate NY (with the exception of falls for adults 85 1 Upstate New York (NY) refers to State of New York less the city of New York City. Preliminary Needs Assessment Report Page 2

5 years and older). The seven causes with higher rates include: unintentional injury - aged 65 years and older, falls - aged years, diabetes (any diagnosis), pneumonia/flu - aged 65 years and older, cardiovascular disease, disease of the heart, and falls - aged years. The high rate of hospitalizations due to falls was noted by key informants and is currently being addressed by a comprehensive, collaborative prevention effort in the county. Table 2: Leading Causes of Premature Death Leading Causes Total Number Rate 1. Cancer * 2. Heart Disease * 3. Unintentional Injury 65 97* 4. CLRD 56 98* 5. Diabetes 26 40* *Rate higher than Upstate NY Data Sources: Vital Statistics Data as of March, 2014 Notes: Premature death data by county includes data from Rate is the age-adjusted rate per 100,000. Table 3: Leading Causes of Hospitalizations Leading Causes Rate 1. Falls - Aged 85 years and older Unintentional injury - Aged 65 years and older 306.0* 3. Falls - Aged years 250.6* 4. Diabetes (any diagnosis) a 5. Pneumonia/flu (aged 65 years and older) 179.7* 6. Cardiovascular disease a, * 7. Disease of the heart a, * 8. Falls - Aged years 86.6* 9. Newborn drug-related 68.7 b 10. Unintentional injury 60.2 a *Rate higher than Upstate NY Data sources: SPARCS/NYS Community Health Indicator Reports (CHIRS) 2011 Rate is crude rate per 10,000 unless otherwise noted. a Rate is age-adjusted per 10,000. b Crude rate per 10,000 newborn discharges. Population Health Indicators and Major Health Risk Factors Table 4 presents the major health risk factors for Cayuga County, NY. Several measures across each of the five categorical areas of risk factors include rates that are worse than those presented for Upstate NY. Of the maternal and infant health measures, the infant mortality rate (per 1,000 live births) for Cayuga County is higher than Upstate NY. Other topical areas that include rates worse than Upstate NY include: tobacco, alcohol, and substance use (specifically: adults who are current smokers, adults with heavy drinking in the past month, alcohol related motor vehicle injuries and deaths), mental health (specifically: adults with poor mental health for 14 or Preliminary Needs Assessment Report Page 3

6 more days in the past month), obesity and related indicators (specifically: children and adolescents (students) who are overweight or obese, adults who are obese, adults with diabetes, adults consuming five fruits or vegetables per day, adults with no leisure-time physical activity) and safety (rate of motor-vehicle mortalities). Table 4: Population Health Indicators and Major Health Risk Factors Major Health Risk Factors Cayuga Upstate New York Maternal and Infant Health** Births with late or no prenatal care (%) Exclusive breastfeeding (%) Cesarean section delivery (%) Infant mortality (per 1,000 live births) Preterm births (%) Low birth weight births (%) Tobacco, Alcohol, and Substance Use Adults who are current smokers (%)* Adults with heavy drinking in the past month (Ageadjusted, %)* Alcohol related motor vehicle injuries and deaths (per 100,000)** Drug-related hospitalizations (Age-adjusted, per 10,000)** Mental Health Percent of adults with poor mental health for 14 or more days in past month* Obesity and Related Indicators Percent of children and adolescents (students) who are overweight or obese(%)*** Adults who are obese (%)* Adults with diabetes (%)* Adults consuming 5 fruits or vegetables per day (Age-adjusted %)* Adults with no leisure-time physical activity (Ageadjusted, %)* Safety Age-adjusted rate of motor-vehicle mortalities per 100,000** Data sources: *BRFSS 2009, **CHAI 2011, *** CHAI 2012 Note: Other variables are available in complete data set. Preliminary Needs Assessment Report Page 4

7 Access to Health Care Table 5 provides an overview of potential indicators related to access to health care for residents of Cayuga County, NY. Several measures represent rates worse than Upstate. These measures include: adults with health insurance, adults with dental visits in the past year, women aged 40 and older who had mammograms in the past two years and adults 65 and older who ever had pneumonia vaccinations. Table 5: Access to Health Care Service Utilization Cayuga Upstate New York Adults with health insurance (%) Adults with regular health care providers (%) Adults with dental visits in past year (%) Women aged 40 and older who had mammograms in the past two years (%) Women who had pap tests in the past three years (%) Adults aged 50 and older who ever had sigmoidoscopies or colonoscopies (%) Adults age 65 and older who had flu shots in the past year (%) Adults age 65 and older who ever had pneumonia vaccinations (%) Data source: BRFSS County-Specific Prevention Agenda Highlights 2009 Note: Other variables are available in complete data set. Utilization Indicators and Health Outcomes among County Medicaid Members Service Utilization Table 6 provides a description of the Medicaid service utilization for Cayuga County, NY for primary care, emergency room and inpatient admissions. The number of unique Medicaid members with at least one visit for primary care, emergency room, and inpatient admissions includes: 18,963, 17,109 and 17,109, respectively for each of the three areas. The percent of county Medicaid members across each area includes: 63% for primary care, 28% for ER and 11% for inpatient admissions. The only area of service utilization that is higher than Upstate NY is ER utilization with 28% of county members with a visit, which represents.6 visits per member. Emergency room visits among Medicaid members is highest in Auburn as well as the surrounding towns of Weedsport, Port Byron, and Union Springs. Medicaid inpatient admissions is highest north of Auburn in the towns of Weedsport and Cato and in the southern tip of the county in King Ferry and Genoa. Preliminary Needs Assessment Report Page 5

8 Table 6: Service Utilization Service Utilization Primary Care Emergency Room Inpatient Admission Number of Unique Members Percent of County Members With a Visit * Total Number of Visits Visits per Member * 0.15 *Rate higher than state Data sources: Health Data New York 2013 (Primary Care), Health Data New York 2012 (ER/Inpatient) The maps below demonstrate geographic differences in ER utilization and inpatient admissions. Auburn (Zip Code 13021) has the highest rate of utilization for ER visits and genoa (13071) has the highest rate of inpatient admissions. Other zip codes with utilization in the worst quartile are highlighted for each indicator.. Preliminary Needs Assessment Report Page 6

9 Causes of Utilization Table 7 describes the percent of Medicaid members with chronic conditions in Cayuga County, NY. Six of the top ten chronic conditions represent rates higher than NY State. The major chronic conditions that are higher than NY State include: depression (12.44%), chronic stress and anxiety diagnoses (5.07%), schizophrenia (3.54%), attention deficit / hyperactivity disorder (3.54%), chronic mental health diagnoses (2.45%) and COPD and major other chronic pulmonary diagnoses (2.45%). Of note: five of the six rates that are higher than the State are for mental health/behavioral health conditions. Table 7: Percent of Members with Chronic Conditions Major Chronic Conditions Number of Members % of Members 1. Depression * 2. Hypertension Diabetes Asthma Chronic Stress and Anxiety * Diagnoses 6. Schizophrenia * 7. Attention Deficit / Hyperactivity * Disorder 8. Chronic Mental Health Diagnoses * 9. COPD and Major Other Chronic Pulmonary Diagnoses * 10. Drug Abuse *Rate higher than NY State Data source: Health Data New York 2012 Table 8 describes the leading causes of ER Visits for Medicaid members in Cayuga County, NY. The table includes both the number of members with the condition and the number of visits per member. All ten of the leading causes of ER visits represent a number of visits that are higher than NY State. The leading causes (ER visits per member with condition) that are higher than NY State include: major personality disorders (4.49), drug abuse (3.71), chronic mental health diagnoses (2.75), post-traumatic stress disorder (2.73), congenital and cardiac defects/anomalies (2.71) bi-polar disorder (2.53), atrial fibrillation, cardiac dysrhythmia, and conduction disorders (2.44), chronic bronchitis and other chronic pulmonary diagnoses (2.43) and conduct, impulse control, and other disruptive behavior Disorders ( 2.43). Of note: seven of the ten causes are higher than the State for mental health/behavioral health conditions. These finding are consistent with key informant statements that behavioral health issues drive emergency room visits whether as a sole diagnosis or a co-morbidity. Preliminary Needs Assessment Report Page 7

10 Leading Causes Ranked by Rate Table 8: Leading Causes of ER Visits Number of Members with Condition Visits per Member with Condition 1. Major Personality Disorders * 2. Drug Abuse * 3. Chronic Alcohol Abuse * 4. Chronic Mental Health Diagnoses * 5. Post Traumatic Stress Disorder * 6. Congenital and Cardiac * Defects/Anomalies 7. Bi-Polar Disorder * 8. Atrial Fibrillation, Cardiac Dysrhythmia, and Conduction Disorders 9. Chronic Bronchitis and other Chronic Pulmonary Diagnoses 10. Conduct, Impulse Control, and Other Disruptive Behavior Disorders *Rate higher than NY State Data source: Healthy Data New York * * * Table 9 describes the leading causes of Inpatient Admissions for Medicaid members in Cayuga County, NY. The table includes both the number of members with the condition and the number of admissions per member with the condition. Two of the ten leading causes of Inpatient Admissions represent a number of admissions that are higher than NY State. The leading causes (admissions per member) that are higher than NY State include: major personality disorders (2.2) and chronic bronchitis and other chronic pulmonary diagnoses (1.06). Preliminary Needs Assessment Report Page 8

11 Table 9: Leading Causes of Inpatient Admissions Leading Causes Ranked by Rate Number of Members with Condition Admissions per Member with Condition 1. Major Personality Disorders * 2. Drug Abuse Chronic Alcohol Abuse History of Myocardial Infarction History of Coronary Artery Bypass Graft 6. Cardiomyopathy, Congestive Heart Failure and Other Cardiovascular Major Diagnoses 7. Atrial Fibrillation, Cardiac Dysrhythmia, and Conduction Disorders 8. History of Percutaneous Transluminal Coronary Angioplasty 9. Congenital and Cardiac Defects/Anomalies Chronic Bronchitis and other Chronic * Pulmonary Diagnoses *Rate higher than NY State Data source: Healthy Data New York 2012 Prevention Quality Indicators Table 10 lists the Prevention Quality Indicators for Cayuga County, NY. The table includes both adults Inpatient Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs). Comparisons of both the PQI and PDI to Upstate indicators are also provided in the table. The PQIs that are higher than Upstate include: diabetes long-term complications, COPD or asthma in older adults, heart failure, dehydration, bacterial pneumonia, angina without procedure, uncontrolled diabetes, and lower extremity amputation (among those with diabetes). The composite PQIs higher than Upstate include the overall, acute, and chronic composites, as well as the circulatory and respiratory composites. The PDIs that are higher than Upstate include: diabetes short-term complications and gastroenteritis. The composite PDI higher than Upstate NY is the acute composite indicator. Preliminary Needs Assessment Report Page 9

12 Table 10: Prevention Quality Indicators (2012) Metric Cayuga Upstate New York Medicaid Inpatient Prevention Quality Indicators (PQIs) Diabetes Short-term Complications Diabetes Long-term Complications * 182 Chronic Obstructive Pulmonary Disease (COPD) or * 800 Asthma in Older Adults Hypertension Heart Failure * 264 Dehydration * 110 Bacterial Pneumonia * 276 Urinary Tract Infection Angina without Procedure 51.35* 22 Uncontrolled Diabetes 42.6* 42 Asthma in Younger Adults Lower Extremity Amputation (among those with 54.17* 18 Diabetes) Medicaid Inpatient PQI Composite Measures Overall Composite PQI * 1783 Acute Composite PQI 710.3* 566 Chronic Composite PQI * 1213 Diabetes Composite Circulatory Composite * 366 Respiratory Composite * 481 Medicaid Inpatient Pediatric Quality Indicators (PDIs) Asthma Diabetes Short-term Complications 79.86* Gastroenteritis * Urinary Tract Infection Medicaid Inpatient PDI Composite Measures Overall Composite PDI Acute Composite PDI 77.71* Chronic Composite PDI *Rate higher than Upstate NY. Note: Rate is risk-adjusted rate per 100,000 admissions. Data sources: Health Data NY 2012 (county data); DSRIP Performance Chartbooks (Upstate NY data) Preliminary Needs Assessment Report Page 10

13 The following maps highlight Zip Codes in the county that have high rates of disease. The first map is of the composite PQI indicator, which includes admissions for one of the following conditions: diabetes with short-term and longterm complications, uncontrolled diabetes without complications, diabetes with lowerextremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection (UTI). The other maps reflect county performance on composite indicators for acute (dehydration, bacterial pneumonia, or UTI) and chronic (diabetes with short-term or long-term complications, uncontrolled diabetes without complications, diabetes with lowerextremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, or angina without a cardiac procedure) illnesses. Across the board, Weedsport (13166) performs poorly on these composite quality indicators. Preliminary Needs Assessment Report Page 11

14 The second set of maps highlights county performance on composite measures for diabetes, respiratory disease, and circulatory disease. Zip Codes with the worst performance on diabetes measures include: Martville (13111), King Ferry (13081), Sterling (13156), and Aurora (13026). Circulatory disease rates are highest in Cato (13033), Martville (13111), Moravia (13118), and Cayuga (13034). High rates of respiratory illness are more concentrated in Auburn (13021), Locke (13092), and Weedsport (13166) Preliminary Needs Assessment Report Page 12

15 The final map is of the overall composite PDI measures. This measure includes admissions for one of the following conditions, among pediatric patients age 6-17 years: asthma, diabetes with short-term complications, gastroenteritis, or urinary tract infection. Cato (13033) has performance in the worst quartile for this pediatric indicator. The following charts compare Cayuga County to ten other nearby counties. Compared to nearby counties, Cayuga performs worse than most counties and worse than the state average on overall PQI composite score (2,258 per 100,000 compared to 1,784 for the state). Preliminary Needs Assessment Report Page 13

16 Compared to most nearby counties, Cayuga performs worse on both the acute composite PQI indicator, and the chronic composite indicator. Compared to nearby counties, Cayuga performs relatively worse on the composite PDI (Pediatric) indicator with a rate that is higher than eight of ten nearby counties. However, Cayuga performed better on the PDI composite indicator than the state average (273.9 in Cayuga vs at the state level). Preliminary Needs Assessment Report Page 14

17 Potentially Preventable ER Visits (PPV) and Readmissions (PPR) The potentially preventable ER visit risk adjusted rate was 44.9 per 100 people in Cayuga County, which is higher compared to the Upstate NY rate of 39 and statewide rate of 36. Auburn Community Hospital in Cayuga County has a lower risk adjusted rate of potentially preventable readmissions (5) than the state (6.73). Table 11: Ranking of Hospitals in Cayuga, by Rate of Potentially Preventable Readmissions (PPR) (2012) Rank Hospital Rate of PPR 1. Auburn Community Hospital 5 Statewide Rate 6.73 *Rate higher than statewide Data source: Health Data NY The graph on the next page compares Cayuga County to other counties in the Upstate NY area. Compared to ten nearby counties, Cayuga County is better than three counties, with a rate of 44.9 potentially preventable emergency room visits per 100 people in the county. This compares unfavorably with the state average of 36.1 visits per 100 people. Preliminary Needs Assessment Report Page 15

18 Within Jefferson, there are a number of zip codes with PPV rates higher than the county rate. These zip codes include: 13024, 13071, and Cayuga County Health Care and Community Resources A total of 18 individuals from Cayuga County responded to the survey. Those responses detailed the health care and community resources available in the county including: a total of 1,147 medical service providers, 77 behavioral health providers, and 201 community based resources. Respondents indicated Cayuga County was under capacity to meet the needs for outpatient primary care services, developmental disability services, behavioral health services, and other health services. Key informants echoed the lack of behavioral health and primary care providers, especially those serving low-income individuals and/or accepting Medicaid patients and report that it is difficult to coordinate with providers outside of Auburn. Maps of the survey respondents and the resource inventory are on the following page. Four maps are presented for: medical service providers, mental/behavioral health providers, community based resource locations, and dental providers. The maps indicate that the majority of available medical, mental/behavioral health and dental resources are concentrated in Auburn. Other regions of the county have few health and community resources. There are few dental provider and mental/behavioral health provider locations across the county. Preliminary Needs Assessment Report Page 16

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20 Nearly all of Cayuga County, including the City of Auburn, is designated by Health Resources and Services Administration (HRSA) as Health Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs), or Medically Underserved Populations (MUPs). Table 12 represents the number of HPSA and MUA/Ps in Cayuga County, as designated by HRSA. Additionally, a map of safety net providers funded by the HRSA and mapped using their Uniform Data System (UDS) is included in Appendix B. Table 12: Designated Shortage Areas Primary Care 25 Dental 1 HPSA Mental Health 2 TOTAL 28 MUA/P 17 Data source: HRSA 8/29/2014 Number of Designations Key Health/Health Care Challenges A close examination of the available data leads to the identification of the following key health care challenges. Key Underlying Challenges in Cayuga County Challenge 1- Lack of Transportation Transportation is a key challenge in Cayuga County. Identified by the majority of respondents as the primary barrier, transportation is especially difficult for those located in rural areas outside of Auburn where there is also a lack of providers. The transportation issue is further compounded in the cold, winter months for individuals without adequate transportation who are less likely to access needed resources. Challenge 2-Lack of Providers A majority of key informants stated that an overall lack of providers is a challenge in Cayuga County. Interviewees reported a lack of primary care, mental health, dental and specialty providers, especially those serving the Medicaid population. Primary care providers serving the Medicaid population are stretched thin. These statements are supported by the various HPSA, MUP and MUA designations throughout the county. Challenge 3-Lack of Coordination and Integration with Behavioral Health A third challenge Cayuga County faces is the lack of coordination and integration with behavioral health. An overwhelming response from behavioral health and community based Preliminary Needs Assessment Report Page 18

21 organizations identified disconnect from other services noting that the highest utilization of emergency services stems from patients with behavioral health diagnoses. One interviewee noted that behavioral health issues drive emergency room use. Non-primary care service providers expressed concern in not being included or considered in partnerships with the hospital. Interviewees identified a need for educating primary care providers on the available community services; breaking down the silos between services providers; and increasing data sharing among providers. Coordination between community providers and the hospital emergency room staff is limited, yet coordination and communication is strong between community providers and the hospital s behavioral health unit. The structure of the emergency room staffing (eg. contracted providers) was noted as a possible reason for the lack of integration and coordination. Challenge 4-Inadequate Crisis Diversion Resource Another challenge identified for Cayuga County was crises diversion. Without the availability of non-crises services during non-working hours, there is higher than average admission and usage of emergency services. Additionally, service providers are receiving referrals for services outside of their scope of services simply because of lack of community resources. Interviewees identified a need for step down services for patients, especially those with behavioral health needs. These step down services would bridge the gap between the most intensive services (eg. hospitalization, residential treatment) and existing community resources. The step down services would support patients as they transition to a less supportive/restrictive environment and prevent usage of emergency services. Challenge 5- Lack of Care Transitions The lack of care transition systems was identified as another challenge for some providers in Cayuga County. Though survey respondents indicated their organizations offer care coordination and/or case management, interviewees expressed frustration with care transition systems. Interviewees indicated a need for discharge planning for the population they serve to enhance communication and coordination between the hospital, community based organizations and providers. Providers that do share data with the hospital through discharge planning and electronic data systems stated these systems help care transitions and envision further improvements as the system improves. Preliminary Needs Assessment Report Page 19

22 Summary: Key Underlying Challenges 1. Lack of Transportation. Limited transportation resources create a barrier to accessing health care, especially for individuals outside of Auburn. 2. Lack of Providers. An overall lack of providers serving the Medicaid population presents a challenge for health care in the county. 3. Lack of Coordination and Integration with Behavioral Health. Poor coordination and integration with behavioral health providers results in limited communication and missed opportunities to reduce emergency room use. 4. Inadequate Crisis Diversion Resources. Lack of after-hours care and step down services, especially for behavioral health needs, increases use of emergency room services. 5. Lack of Care Transitions. Lack of discharge planning and data sharing between the hospital and some providers impacts patient health status and possible readmission. Comparison to Past Needs Assessments Challenges identified in this needs assessment are similar to those that have been found in Cayuga County in past needs assessments. Cayuga County Health Department s Community Health Assessment (CHA) & Community Health Improvement Plan (CHIP) identified many of the same health indicators, including the major health risk factors, highlighted in this needs assessment. The difference is that the DSRIP interviews highlight significant challenges in care coordination, integration and crisis diversion among providers in the community due to the focus on hospital readmissions among Medicaid patients. Transportation, especially outside of Auburn is an ongoing challenge for the county. The integration of behavioral health is also an ongoing challenge that is being brought to the forefront with the opportunity for behavioral health organizations to be given a voice. Preliminary Needs Assessment Report Page 20