Family Health Centers of Southwest Florida Community Health Assessment

Transcription

1 2014 Community Health Assessment Prepared by: The Health Planning Council of Southwest Florida, Inc.

2 Community Health Assessment Committee Members created a community committee comprised of area residents, business leaders, and medical professionals who showed an interest in improving the health of their community. This group held regular meetings for the duration of the project to aid in the creation and implementation of this needs assessment. Below is a list of participating members of the s Community Health Assessment Committee. Marie Andress Edward Houck Health Planning Council of Southwest Florida Bob Beville Waterman Broadcasting John Koehler Melinda Black Kevin Lewis SalusCare Kathy Bridge-Liles Lee Memorial Health Systems Frank Mazzeo Peggy Brown Health Planning Council of Southwest Florida Leah McCann Keller Williams Realty Teri Buchanan Chris Nesheim Lee Memorial Health Systems Veronica Culbertson Southwest Florida Hispanic Chamber of Commerce Jorge Quinonez Joanne Dill Children s Medical Services Emad Salman Lee Memorial Health Systems Rachel Dwyer Community Volunteer Fred Schilffarth Lee County Homeless Coalition Josephine Gagliardi Lee County Justice Center Jennifer Sexton Health Planning Council of Southwest Florida Judith Hartner Florida Department of Health, Lee County Roger Ward 1

3 Table of Contents Introduction... 8 Demographic and Socioeconomic Characteristics... 9 Population Demographics Age Gender Race and Ethnicity Socioeconomic Indicators Health Status Health Ranking Healthy People 2020 Objectives Death Rate Chronic Diseases Heart Disease Cancer Diabetes Communicable Diseases Sexually Transmitted Diseases Vaccine Preventable Diseases AIDS and Other Diseases Maternal and Child Health Teen Births Infant Deaths Mothers Who Smoked During Pregnancy Oral Health Accessibility for Low-Income Residents Dental Emergencies Social and Mental Health Crime and Domestic Violence Alcohol-related Motor Vehicle Crashes Florida Youth Substance Abuse Survey Suicides Baker Act Hospitalizations Prevention Quality Indicators

4 Chronic Conditions Emergency Room Visits Health Resources Medicaid Florida KidCare Uninsured Physicians and Facilities Federal Health Professional Shortage Designations Medically Underserved Areas / Medically Underserved Populations Health Professional Shortage Areas Community Input Survey on Health and Healthcare Interviews with Community Leaders Appendices: Appendix A: Lee County Data Lee County Demographic and Socioeconomic Characteristics Population Demographics Population Growth Age Gender Race and Ethnicity Socioeconomic Indicators Lee County Health Status Health Ranking Healthy People 2020 Objectives Death Rate Death Rates by Race Leading Cause of Death Chronic Diseases Cancer Heart Disease Diabetes Communicable Diseases Sexually Transmitted Diseases

5 Vaccine Preventable Diseases AIDS and Other Diseases Maternal and Child Health Teen Births Infant Deaths Mothers Who Smoked During Pregnancy Oral Health Accessibility for Low-Income Residents Dental Emergencies Social and Mental Health Crime and Domestic Violence Alcohol-related Motor Vehicle Crashes Florida Youth Substance Abuse Survey Suicides Baker Act Hospitalizations Prevention Quality Indicators Chronic Conditions Emergency Room Visits Lee County Health Resources Medicaid Florida KidCare Uninsured Physicians and Facilities Lee County Behavioral Risk Factor Surveillance Survey Appendix B: Charlotte County Data Charlotte County Demographic and Socioeconomic Characteristics Population Demographics Population Growth Age Gender Race and Ethnicity Socioeconomic Indicators Charlotte County Health Status Health Ranking

6 Healthy People 2020 Objectives Death Rate Death Rates by Race Leading Causes of Death Chronic Diseases Heart Disease Cancer Diabetes Communicable Diseases Sexually Transmitted Diseases Vaccine Preventable Diseases AIDS and Other Diseases Maternal and Child Health Teen Births Infant Deaths Mothers Who Smoked During Pregnancy Oral Health Accessibility for Low-Income Residents Dental Emergencies Social and Mental Health Crime and Domestic Violence Alcohol-related Motor Vehicle Crashes Florida Youth Substance Abuse Survey Suicides Baker Act Hospitalizations Prevention Quality Indicators Chronic Conditions Emergency Room Visits Charlotte County Health Resources Medicaid Florida KidCare Uninsured Physicians and Facilities Charlotte County Behavioral Risk Factor Surveillance Survey Appendix C: Hendry County Data

7 Hendry County Demographic and Socioeconomic Characteristics Population Demographics Population Growth Age Gender Race and Ethnicity Socioeconomic Indicators Hendry County Health Status Health Ranking Healthy People 2020 Objectives Death Rate Death Rates by Race Leading Causes of Death Chronic Diseases Heart Disease Cancer Diabetes Communicable Diseases Sexually Transmitted Diseases Vaccine Preventable Diseases AIDS and Other Diseases Maternal and Child Health Teen Births Infant Deaths Mothers Who Smoked During Pregnancy Oral Health Accessibility for Low-Income Residents Dental Emergencies Social and Mental Health Crime and Domestic Violence Alcohol-related Motor Vehicle Crashes Florida Youth Substance Abuse Survey Suicides Baker Act Hospitalizations Prevention Quality Indicators

8 Chronic Conditions Emergency Room Visits Hendry County Health Resources Medicaid Florida KidCare Uninsured Physicians and Facilities Hendry County Behavioral Risk Factor Surveillance Survey Appendix D: Definitions of Prevention Quality Indicators Appendix E: Health Needs Survey Appendix F: Key Informant Interview Guide Appendix G: Community Leaders Interviewed Appendix H: Family Health Centers Guide to Healthcare Services Appendix I: Selected Data Sources

9 Introduction In an effort to improve the health of the residents of southwest Florida, a collaborative partnership was formed between and the Health Planning Council of Southwest Florida, Inc. (HPC) for the purpose of conducting a community health needs assessment for use by and other community partners. The geographic focus of this assessment included all areas that currently serves: Lee County, Charlotte County, and the western half of Hendry County*. HPC reviewed numerous data sources and received feedback from the Community Health Assessment Committee 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. *For the sake of simplicity, Hendry County is examined in its entirety throughout most of this assessment. 8

10 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. As shown in Figure 1, has a service area that covers Lee County, Charlotte County, and the western half of Hendry County. Figure 1: 9

11 Population Demographics The sheer number of people in a community is the leading determinant of the demand for healthcare services. While has a service area that encompasses three counties, the vast majority of this area s total population (76%) reside in Lee County. The total population for these three counties is 835,143 and 635,496 of these are Lee County residents. Chart 1: Total Population of Lee, Charlotte, and Hendry Counties , , , , , , , , ,110 38,537 Lee County Charlotte County Hendry County Source: The Florida Legislature, Office of Economic and Demographic Research The population of each of these three counties has grown over the last fifteen years. Hendry County s population has increased 12 percent since Charlotte s County s population has increased 19 percent in that same time. Lee County has seen the largest increase with 52 percent population growth since The population of southwest Florida increases seasonally, causing an increase in the use of health services during the winter months. A 2000 report by the Southwest Florida Regional Planning Council on southwest Florida demographics indicated that the population of the region can increase by as much as 22 percent during the winter. Naples News reported in 2004 that the temporary population in Lee County accounted for 8.2 percent of Florida s temporary population, the largest amount of all of the counties in Florida. Refer to the Population Demographics section of Appendices A (Lee), B (Charlotte), and C (Hendry) for detailed data on population growth, and estimates of future population growth for each of these counties. 10

12 The combined areas of Lee, Charlotte, and Hendry counties (approximately 3,260 square miles) make up nearly 5 percent of the total area of the state of Florida. Lee County and Hendry County are nearly identical in size (1,212 total square miles Lee vs. 1,190 total square miles Hendry); the differences in the density of their population sizes are staggering. According to the population projections published by the Executive Office of the Governor, Lee County has a population density of approximately 808 persons per square mile (of land), while Hendry County has a population density of only 34 persons per square mile (of land). Charlotte County is in between, with an approximate population density of 235 persons per square mile with a total size (land and water included) of 859 square miles. These figures compare to a population density of 357 persons per square mile for the state of Florida as a whole. Chart 2: Population Density of Lee, Charlotte, and Hendry Counties Lee County Charlotte County Hendry County Source: Population Projections, Executive Office of the Governor, Published February

13 Figure 2 shows the sixteen Family Health Centers locations within these three counties. Currently there is one location in Charlotte County, a medical and dental office in Port Charlotte. Hendry County has one location also, a medical and dental office in LaBelle. has fourteen medical and/or dental facilities in Lee County, seven of these are in Fort Myers, two in Bonita Springs, three in Lehigh Acres, and one is in St. James City. The executive office is located in Fort Myers as well, but is not indicated on the map. Figure 2: Source: UDS Mapper. Available at Accessed November 21, indicates a Family Health Centers Location in Lee, Charlotte, or Hendry are preparing to have a new clinic in Estero, opening in May, 2014 as well as a new office in Cape Coral that will provide adult medicine and dental care. 12

14 , as a Federally Qualified Health Center (FQHC) aims to provide healthcare services to all persons regardless of their ability to pay or health insurance status. While many area residents are served by the facilities available, there are still many low-income residents in Family Health Centers service area who are not currently being served by any of the local health centers. The dot density map in Figure 3 displays the estimated number of low-income residents (those who are at or below 200% of the Federal Poverty Level) in the given ZIP Code Tabulation Area (ZCTA) who are not served by any health centers (1 red dot = 100 people randomly placed in the ZCTA). Figure 3: Source: UDS Mapper. Available at Accessed November 21, Data from UDS reporting year 2012, and American Community Survey (ACS) five-year estimates at the ZIP Code Tabulation Area (ZCTA) level; prepared by John Snow, Inc. The number is calculated by subtracting the number of total health center patients reported in the UDS as residing in that ZCTA (from all health centers with 11 or more patients residing in that ZCTA) from the number of low-income residents in that same ZCTA. Because income is not reported in the UDS at the ZIP Code level, this measure is only an estimate and should be interpreted as such. 13

15 Looking at the dot-density map more closely, we can see specific parts of the counties served by Family Health Centers that are more densely populated with low-income individuals who are not served by any health centers. On the north end of Family Health Centers service area, Port Charlotte, in Charlotte County shows a larger proportion of those low-income individuals who are not served by a health center. Figure 4: Source: UDS Mapper. Available at Accessed December 20, Data from UDS reporting year 2012, and American Community Survey (ACS) five-year estimates at the ZIP Code Tabulation Area (ZCTA) level; prepared by John Snow, Inc. The number is calculated by subtracting the number of total health center patients reported in the UDS as residing in that ZCTA (from all health centers with 11 or more patients residing in that ZCTA) from the number of low-income residents in that same ZCTA. Because income is not reported in the UDS at the ZIP Code level, this measure is only an estimate and should be interpreted as such. 14

16 In Lee County, there are several areas that have a larger number of dots. The eastern end of Cape Coral, for example, has more low-income residents who are not being served by a health center. North Fort Myers and Fort Myers areas near the Caloosahatchee River have a larger proportion of that same population as well, as does the southwest end of Lehigh Acres. West Hendry County is shown in Figure 5, and does not show a large number of low-income residents who are not being served by any health center. Figure 5: Source: UDS Mapper. Available at Accessed December 20, Data from UDS reporting year 2012, and American Community Survey (ACS) five-year estimates at the ZIP Code Tabulation Area (ZCTA) level; prepared by John Snow, Inc. The number is calculated by subtracting the number of total health center patients reported in the UDS as residing in that ZCTA (from all health centers with 11 or more patients residing in that ZCTA) from the number of low-income residents in that same ZCTA. Because income is not reported in the UDS at the ZIP Code level, this measure is only an estimate and should be interpreted as such. 15

17 There is a number of dots in the Bonita Springs area, indicating a number of low-income residents in that area who are not receiving services from a health center, but the dots are not nearly as dense as other areas further north in Lee County. Figure 6: Source: UDS Mapper. Available at Accessed December 20, Data from UDS reporting year 2012, and American Community Survey (ACS) five-year estimates at the ZIP Code Tabulation Area (ZCTA) level; prepared by John Snow, Inc. The number is calculated by subtracting the number of total health center patients reported in the UDS as residing in that ZCTA (from all health centers with 11 or more patients residing in that ZCTA) from the number of low-income residents in that same ZCTA. Because income is not reported in the UDS at the ZIP Code level, this measure is only an estimate and should be interpreted as such. 16

18 Age The largest proportion of the population for the counties that encompass Family Health Centers service area is between the ages of 45 and 64, which is the same for the state. Nearly twenty-eight percent of the residents in Lee, Charlotte, and Hendry counties are in this age group. Twenty-five percent of the residents in these three counties make up the elder population, aged 65 and older, which is higher than the state rate of only eighteen percent. The largest proportion of the population of Lee and Charlotte counties is between the ages of 45 and 64. Lee and Charlotte counties have a larger elder population, aged 65 and older, than the state as a whole (23.7% Lee, 34.5% Charlotte vs. 18.0% State). In Hendry County the largest proportion of the population is between the ages of 25 and 44, and Hendry County has a much smaller elder population, aged 65 and older, than Lee and Charlotte counties (12.3% Hendry). Similarly, Lee and Charlotte counties have higher median ages than the state as a whole (45.6 Lee, 55.9 Charlotte vs State), while Hendry has a lower median age (32.8). Gender Women make up a larger proportion of the United States population as a whole and tend to live longer than men. For the counties covered by Family Health Centers service area, this same proportion holds true. Women make up 50.9 percent of Lee, Charlotte, and Hendry counties combined populations. This trend is mirrored in Lee and Charlotte counties where women account for slightly more than half of the population. Hendry County, however, has the opposite proportion percent of the residents of Hendry County are male while 46.9 percent are female; statewide the percentages are 51.1 percent female and 48.9 percent male. It is not uncommon for men to outnumber women in rural areas. 17

19 Race and Ethnicity The white population accounts for the majority of residents in each of the three counties, as well as the state of Florida as a whole. For Lee, Charlotte, and Hendry counties populations combined, as shown in Chart 3, white residents make up 87.8 percent of the combined population, black residents make up 8.6 percent of the population, and only 3.6 percent of the population identify 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. Hendry County has a larger percentage of black residents than Lee and Charlotte, but has fewer black residents than the state average. Charlotte County has a larger proportion of white residents than Hendry, Lee, and the state as a whole, with fewer than ten percent of the population not identifying as white. 100% 90% 80% Chart 3: Population by Race % 3.1% 4.4% 3.6% 5.0% 6.1% 8.9% 8.6% 13.9% 16.6% 70% 60% 50% 40% 87.5% 90.8% 81.7% 87.8% 78.4% Other Black White 30% 20% 10% 0% Lee Charlotte Hendry Combined State Source: The Florida Legislature, Office of Economic and Demographic Research 18

20 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. The combined populations of the three counties that Family Health Centers serves have a lower rate of Hispanic residents than the state as a whole (18.1% Combined vs. 23.2% State). Very few black and other non-white residents identify as Hispanic. Of the three counties that Family Health Centers serves, Charlotte County has the lowest population of Hispanic residents (6.1%), while Hendry County has the highest population of Hispanic residents (50.5%). Table 1: Race and Ethnicity, 2012 Lee Charlotte Hendry Combined State Non-Hispanic Hispanic Non-Hispanic Hispanic Non-Hispanic Hispanic Non-Hispanic Hispanic Non-Hispanic Hispanic White 17.5% 70.0% 5.4% 85.4% 47.7% 34.0% 16.5% 71.3% 21.2% 57.1% Black 0.9% 8.0% 0.4% 5.7% 1.3% 12.6% 0.9% 7.8% 1.2% 15.4% Other 0.8% 2.8% 0.3% 2.8% 1.5% 2.9% 0.7% 2.8% 0.8% 4.3% Total 19.2% 80.8% 6.1% 93.9% 50.5% 49.5% 18.1% 81.9% 23.2% 76.8% Source: The Florida Legislature, Office of Economic and Demographic Research 19

21 Socioeconomic Indicators The figures shown below summarize some of the primary indicators of economic health for the county and state. All three counties show higher unemployment rates than the state rate (8.6%), with Hendry County having the highest rate of the three (13.7%). Of those living below the poverty level, Charlotte County has the lowest rate (13.2%) while Hendry County has the highest rate (29.6%). When it comes to those under the age of 18 living below the Federal Poverty Level, again Charlotte County has the lowest rate (24.2%) while Hendry County has the highest rate (39.8%). The state average for youth living below the poverty level was 25.1 percent. Table 2: Socioeconomic Indicators, 2012 (except where noted) Lee Charlotte Hendry State Labor Force as a % of Pop. Aged % 50.90% 59.40% 62.50% Personal Bankruptcy Filing Rate per 1, Unemployment Rate 8.9% 11.9% 13.7% 8.6% Average Annual Wage $36,478 $31,488 $33,799 $42,446 Per Capita Personal Income $43,022* $35,161* $28,285* $39,636* % Living Below Poverty Level 15.3%* 13.2%* 29.6%* 17.0%* % ages 0-17 living below Poverty 25.9%* 24.2%* 39.8%* 25.1%* Source: The Florida Legislature, Office of Economic and Demographic Research *2011 data Residents of Lee and Charlotte counties have higher percentages of their populations who are high school graduates than the state average, while Hendry County has a significantly lower percentage of residents who are high school graduates. When it comes to the percentage of residents who hold a Bachelor s degree or higher, Hendry County has the lowest percentage of the group, Lee and Charlotte counties are also below the state average of twenty-six percent. Table 3: Educational Attainment, Persons aged 25 and older Lee Charlotte Hendry State % High School graduate or higher 87.0% 88.4% 63.5% 85.5% % Bachelor's degree or higher 24.6% 20.9% 9.4% 26.0% Source: The Florida Legislature, Office of Economic and Demographic Research 20

22 Among working adults in Lee, Charlotte, and Hendry counties the most common sectors of employment are: education and health services, retail trade, and leisure and hospitality. Lee and Charlotte counties also have high rates of employment in professional and business services, while Hendry County has the largest proportion of working adults earning a living in agriculture, forestry, fishing and mining. Table 4: Average Employment by Category, 2012 (except where noted) Lee Charlotte Hendry* State Education & health services 21.3% 20.3% 15.8% 21.5% Retail trade 16.2% 18.2% 14.3% 13.8% Professional and business services 12.4% 13.8% 3.6% 12.6% Leisure & hospitality 14.3% 11.1% 11.3% 12.0% Financial activities 7.2% 7.5% 2.8% 7.7% Construction 8.5% 6.1% 6.8% 6.2% Manufacturing 3.3% 4.1% 3.9% 5.3% Other services 4.7% 6.0% 4.0% 5.3% Public administration 3.6% 4.9% 7.1% 4.9% Transportation, warehousing, & utilities 3.7% 4.0% 6.1% 4.9% Wholesale trade 2.2% 2.1% 0.9% 2.9% Information 1.7% 1.4% 0.2% 1.9% Agriculture, forestry, fishing & mining 0.9% 0.5% 23.0% 1.1% Source: Florida Legislature, Office of Economic and Demographic Research *Data for Hendry County is for , as 2012 data was not yet available. 21

23 Health Status Health Ranking County Health Rankings & Roadmaps, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, ranks each county in two different categories: Health Outcomes and 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. Lee County was ranked 11 th, Charlotte County was ranked 28 th and Hendry County was ranked 32 nd healthiest out of the 67 counties in the state of Florida for Health Outcomes. The Health Outcomes portion of the rankings includes data on mortality and morbidity. Lee County was ranked the 10 th healthiest of all of the Florida counties for mortality, which is based on the years of potential life lost before the age of 75. The Health Factors portion of the rankings includes data on health behaviors, clinical care, social & economic factors, and physical environment. Lee County was ranked 24 th, Charlotte County was ranked 18 th and Hendry County was ranked 63 rd healthiest out of the 67 counties in the state of Florida for Health Factors. For clinical care, Charlotte County was ranked as the 7 th healthiest county. Clinical care includes data on the number of uninsured, primary care physicians, dentists, preventable hospital stays, diabetic screening, and mammography screening. Charlotte County ranked high in clinical care partly due to higher than average rates of diabetic and mammography screenings. For clinical care, Hendry County was ranked as the 64 th healthiest county. In Hendry County, the hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees (93) was higher than that of the state average (65) and considerably higher than the national benchmark (47). Additionally, the percent of female Medicare enrollees that receive mammography screening in Hendry County (62%) was lower than the state average (70%) and the national benchmark (73%). Social & economic factors, where Hendry County ranked 67 th healthiest out of 67 counties in Florida (or the least healthy), includes rates of high school graduation, some college, unemployment, children in poverty, inadequate social support, children in single-parent households, and violent crime. Hendry County ranked poorly due to high rates of unemployment, violent crime, children living in poverty, and children living in single-parent households, as well as low rates of high school graduation and the percent of adults aged years with some post-secondary education. 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, Lee County ranked 10 th healthiest. Lee County had lower than average rates of daily fine particulate matter (6.8 micrograms per cubic meter) than the state average (8.4) and the national benchmark (8.8). Refer to the County Health Rankings section of Appendices A (Lee), B (Charlotte), and C (Hendry) for detailed data for each of the categories that were ranked, and definitions of health measures. 22

24 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. 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. Healthy People 2020 contains 42 topic areas with nearly 600 objectives, which encompass 1,200 measures. Table 6 compares the national targets for sixteen of the health objectives with data taken from their equivalent measures from the 2010 Behavioral Risk Factor Surveillance Survey. Lee County has shown the most progress in the percentage of adult current smokers who tried to quit smoking in the past year (50.8% 2007 vs. 64.2% 2010), but hasn t reached the target of 80.0 percent. Charlotte County had fewer diabetic survey respondents who had an annual eye exam in 2010 than 2007 (83.6% 2007 vs. 71.4% 2010), but still was well above the national target of 58.7 percent. Hendry County showed significantly progress from 2007 in the percentage of adults with diabetes who had two A1C tests in the past year (63.1% 2007 vs. 79.1% 2010), and was above the national target of 71.1 percent. All three counties could use improved percentages of adults receiving recommended cancer screenings, as well as flu and pneumonia vaccinations. All three counties met, and exceeded, the target for the objective Reduce the proportion of persons engaging in binge drinking of alcoholic beverages. 23

25 Table 5: Healthy People 2020 Objectives and Targets Compared to 2010 BRFSS Measures Objective Measure Target Lee Charlotte Hendry AOCBC-2. Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms. 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. 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. IID Increase the percentage of non-institutionalized adults aged 65 years and older who are vaccinated against seasonal influenza. IID Increase the percentage of non-institutionalized adults aged 65 years and older who are vaccinated against pneumococcal disease. Percentage of adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 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. 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 selfmanagement education. Percentage of adults with diagnosed hypertension. Percentage of adults age 65 and over who received a flu shot in the past year. Percentage of adults age 65 and over who have ever received a pneumonia vaccination. 35.5% Meets Target Meets Target 93.0% 70.5% 81.1% 81.1% 74.8% 58.7% Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement 71.1% Meets Target 70.4% 62.5% 26.9% 90.0% 90.0% Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Meets Target Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement 24 Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Meets Target Meets Target Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement

26 NWS-8. Increase the proportion of adults who are at a healthy weight. Percentage of adults who have a healthy weight (BMI from 18.5 to 24.9). 33.9% Meets Target Meets Target Needs Improvement NWS-9. Reduce the proportion of adults who are obese. Percentage of adults who are obese. 30.5% Meets Target Meets Target Needs Improvement 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 who engage in heavy or binge drinking. Percentage of adult current smokers who tried to quit smoking at least once in the past year. 24.4% Meets Target Meets Target Meets Target 80.0% Needs Improvement Needs Improvement Source: U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People Washington, DC. Available at Accessed September 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 25

27 Death Rate The death rates for Lee County and Charlotte County have been consistently lower than the state average over the last twenty years, as shown in Chart 4. Hendry County has had death rates higher than the state average consistently over the last twenty years. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100, Chart 4: Death Rates from All Causes Compared to State Age-Adjusted Rate per 100,000, 3-Year Rates Lee Charlotte Hendry State Source: Florida Department of Health, Office of Vital Statistics Age-Adjusted death rates are computed using the year 2000 standard population. Table 7 shows the most recent three-year data. Hendry County s death rate has declined over the last three years, and is just slightly higher than the state average. Lee and Charlotte counties have remained well below the state rate. Table 6: Age-Adjusted All Causes Death Rate Lee Charlotte Hendry State Source: Florida Department of Health, Office of Vital Statistics Refer to the Death Rate section of Appendices A (Lee), B (Charlotte), and C (Hendry) for detailed data on death rates by race, and a breakdown of the major causes of death for each of these counties. 26

28 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. Heart Disease Heart disease is the leading cause of death nationally for both men and women. Similarly, in Charlotte and Hendry counties, heart disease is the leading cause of death. Heart disease is the second most common cause of death for Lee County residents. Lee and Charlotte counties have death rates from heart disease slightly lower than the state average, while Hendry County has historically had significantly higher rates than the state. Hendry County s death rates from heart disease have been on the decline in recent years. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100, Chart 5: Deaths from Heart Disease Age-Adjusted Rate per 100,000, 3-Year Rates Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics Refer to the Chronic Diseases section of Appendices A (Lee), B (Charlotte), and C (Hendry) for a breakdown by income of adults who have ever had a heart attack, angina, or coronary heart disease in each of these counties. 27

29 Cancer According to the Centers for Disease Control and Prevention, cancer is the second leading cause of death nationally. One of every four deaths in the United States is due to cancer. Cancer is the leading cause of death in Lee County, and comes in second in Charlotte and Hendry counties. Age-adjusted death rates for deaths due to cancer have seen an overall decline over recent years. For the three year period from 2010 to 2012, Lee, Charlotte, and Hendry counties all have rates slightly below the Florida state average. 250 Chart 6: Deaths from All Cancers Age-Adjusted Rate per 100,000, 3-Year Rates Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics 28

30 Among the more than 100 types of cancer, lung cancer claims the most lives. Fortunately, death rates for lung cancer have seen a declining trend for Lee, Charlotte, and Hendry counties, as well as the state of Florida as a whole, as shown in Chart 8. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100,000. Chart 7: Deaths by Cancer Type Age-Adjusted Rate per 100,000, Lee Charlotte Hendry State Lung Cancer Breast Cancer Prostate Cancer Colorectal Cancer Cervical Cancer Skin Cancer Source: Florida Department of Health, Office of Vital Statistics Chart 8: Deaths from Lung Cancer Age-Adjusted Rate per 100,000, Lee Charlotte Hendry State Source: Florida Department of Health, Office of Vital Statistics 29

31 Rates of cancer incidence, the number of new cancers during a year, have fluctuated slightly over recent years. Lee and Hendry counties have seen a slight decline in cancer incidence most recently, while Charlotte County residents have seen a slight increase during the same time. 600 Chart 9: Cancer Incidence Age-Adjusted Rate per 100,000, 3-Year Rates Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics Refer to the Chronic Diseases section of Appendices A (Lee), B (Charlotte), and C (Hendry) for a comparison of death rates and incidence of common types of cancer in each of these counties, as well as a breakdown by income of adults who have had various cancer screenings. 30

32 Diabetes Diabetes, while not nearly as deadly as heart disease and cancer, is still a major health concern in the United States. It is ranked as the seventh leading cause of death nationally, and can cause heart disease, blindness, kidney failure, and lower-extremity amputations. Age-adjusted death rates due to diabetes have been on the decline recently in Lee and Hendry counties. Rates in Charlotte County have seen a slight increase, and are currently higher than the state average. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100,000. For example, for the three year period from 2010 through 2012, Lee County had 364 deaths due to diabetes, Charlotte County had 214 deaths due to diabetes, and Hendry County had a total of 34 deaths due to diabetes. 70 Chart 10: Deaths from Diabetes Age-Adjusted Rate per 100,000, 3-Year Rates Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics Refer to the Chronic Diseases section of Appendices A (Lee), B (Charlotte), and C (Hendry) for data on adults with diagnosed diabetes broken down by sex and income level for each of these counties. 31

33 Communicable Diseases Communicable diseases, also referred to as infectious diseases, are a constant health concern. Sexually Transmitted Diseases Chlamydia is the most commonly reported sexually transmitted disease in the United States. Rates of reported cases of chlamydia have been climbing steadily over the last fifteen years. While some of this increase may directly be due to an increase in actual chlamydia cases, it is also due in part to better testing methods. Hendry County shows significantly higher rates of reported chlamydia cases than Lee and Charlotte counties, which can likely be attributed to their younger population. Chlamydia is most common among young people. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100,000. For example, for the three year period from 2010 through 2012, Lee County had 6,110 reported cases of chlamydia, Charlotte County had 912 reported cases, and Hendry County had 620 reported cases. 600 Chart 11: Chlamydia Cases 3-Year Rate per 100, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of STD Prevention & Control 32

34 Vaccine Preventable Diseases Pertussis, a respiratory disease that is commonly known as whooping cough, is currently the most prevalent vaccine preventable disease in Lee County and Hendry County. Hendry County in particular has seen an increase in the number of reported pertussis cases, and is at its highest rate in twenty years (6.7 cases per 100,000). Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100,000. Table 8 shows counts of actual cases reported in each county. 8 Chart 12: Pertussis Cases 3-Year Rate per 100, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Epidemiology Table 7: Pertussis Cases Single Year Counts Lee Charlotte Hendry Source: Florida Department of Health, Bureau of Epidemiology 33

35 Hepatitis B, a contagious liver disease, is the most common vaccine preventable disease in Charlotte County. Hendry County has had no reported cases of Hepatitis B in recent years. 14 Chart 13: Acute Hepatitis B Cases 3-Year Rate per 100, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Epidemiology 34

36 AIDS and Other Diseases An average of 67 people per year was diagnosed with AIDS across the counties that Family Health Centers serves between 2010 and Chart 14 shows the rate per 100,000 population for each of these counties as compared to the state of Florida as a whole. This comparison illustrates a downward trend in diagnosed AIDS cases for each of these counties as well as the state as whole, with the state average being consistently higher than Lee, Charlotte, and Hendry counties. 60 Chart 14: AIDS Cases 3-Year Rate per 100, Lee Charlotte Hendry State 10 0 Source: Florida Department of Health, Bureau of HIV/AIDS 35

37 The rate of tuberculosis, an infectious bacterial disease, has been fairly low in Lee and Charlotte counties, with rates mostly below the state average. Hendry County has seen more sporadic, higher rates of tuberculosis cases, but in recent years Hendry County has trended downwards. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100, Chart 15: Tuberculosis Cases 3-Year Rate per 100, Lee Charlotte Hendry State 0 Source: Florida Department of Health, Bureau of TB and Refugee Health Refer to the Communicable Diseases section of Appendices A (Lee), B (Charlotte), and C (Hendry) for detailed data on sexually transmitted diseases, vaccine preventable diseases, and AIDS and other diseases for each of these counties. 36

38 Maternal and Child Health On average, 7,946 babies were born per year between 2010 and 2012 across the counties that Family Health Centers serves. 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. Teen Births 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 for births to mothers that are between the ages of 10 and 14 are relatively low (fewer than 2 births per 1,000 population). The number of births to older teenage mothers is significantly higher. Lee and Charlotte counties have rates similar to the state average (31.9 Lee, 30.5 Charlotte vs State), while Hendry County has much higher rates (61.1) Chart 16: Births to Mothers ages per 1,000 3-Year Figures, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics 37

39 Overall, the rates of births to young mothers, between the ages of 10 and 19, have been declining steadily over the last twenty years. As with births to older teenage mothers, Hendry County has the highest rates of births to mothers ages Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 1,000. For example, for the three year period from 2010 through 2012, Lee County had 1,658 births to mothers ages 10-19, Charlotte County had 313 births, and Hendry County had 265 births. 70 Chart 17: Births to Mothers ages Year Rate per 1, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics 38

40 Infant Deaths 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. The rates in Chart 18 for infant deaths per 1,000 live births have been extremely sporadic, particularly for Charlotte and Hendry counties. The most recent rates for all three counties that Family Health Centers serves have fallen below the rates for the state of Florida as a whole. 14 Chart 18: Infant Deaths (0-364 days) 3-Year Rate per 1, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics 39

41 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). Of the three counties that Family Health Centers of Southwest Florida serves, Charlotte County has the highest rates of births to mothers who smoked during their pregnancy. Lee County has rates significantly lower than those in Charlotte County, but that are higher than the state average. Hendry County has particularly low rates of births to mothers who smoked while pregnant compared to the other counties. 30 Chart 19: Births to Mothers Who Smoked During Pregnancy 3-Year Rate per 1, Lee Charlotte Hendry State 0 Source: Florida Department of Health, Bureau of Vital Statistics Refer to the Maternal and Child Health section of Appendices A (Lee), B (Charlotte), and C (Hendry) for detailed data on maternal and child health indicators for each of these counties. 40

42 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 medical complications that can result from minimal oral care and treatment, linking oral diseases with ear and sinus infections, weakened immune systems, heart and lung diseases, and other health conditions. Chart 20 details the adults who reported on the Behavioral Risk Factor Surveillance Survey that they had visited a dentist or dental clinic in the past year as well as those who reported that they had their teeth cleaned during that same time. Charlotte County showed rates higher than Lee and Hendry counties as well as the state of Florida as a whole % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Chart 20: Dental Visits and Teeth Cleanings in the Past Year 2010 Lee Charlotte Hendry State Adults Who Visited a Dentist or Dental Clinic in the Past Year Adults Who Had Their Teeth Cleaned in the Past Year 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]. Refer to the Oral Health section of Appendices A (Lee), B (Charlotte), and C (Hendry) for a detailed breakdown of this data by income for each of these counties. 41

43 Accessibility for Low-Income Residents According to data from the Florida Department of Health Public Health Dental Program, Lee and Hendry counties have similar rates of access to dental care for low-income persons as the state as a whole. Charlotte County, however, shows a significantly lower percentage of low-income persons with access to dental care than the state, although the rates have been increasing in recent years. 40 Chart 21: Percentage of Low-Income Persons* with Access to Dental Care 3-Year Rate Lee Charlotte Hendry State Figure 7: Source: Florida Department of Health, Public Health Dental Program *Low-Income Persons are defined as those living below the poverty level. Access to dental care for many low-income individuals means having healthcare coverage through the Medicaid program. Healthcare providers are not required to see Medicaid patients, and those who do often only see a limited number of patients who are insured under Medicaid. As of December 2013, there were eight Medicaid dental providers in Lee County, two in Charlotte County, and three in Hendry County (849 statewide). This number includes county health departments and federally qualified health centers. The services that are paid for through Medicaid are limited, especially for adults. Source: Florida Department of Health, Public Health Dental Program 42

44 Dental Emergencies A lack of access to routine dental care can lead to avoidable visits to the local emergency room and avoidable hospitalizations. Lee, Charlotte, and Hendry counties had a combined 3,944 emergency room visits for dental conditions that are generally considered avoidable with appropriate preventive care in the twelve months from April, 2012 through March, The charges for these avoidable visits totaled $3,112,497. Preventable hospitalizations for patients under the age of 65 for dental conditions have fluctuated over the years. Most recently these numbers have been rising in all three counties. 16 Chart 22: Preventable Hospitalizations Under 65 from Dental Conditions* 3-Year Rate per 100, Lee Charlotte Hendry State Source: Florida Agency for Health Care Administration (AHCA) *Rates are for hospitals in Lee, Charlotte, and Hendry counties. Patients are not necessarily residents of these counties. 43

45 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 Lee County and Hendry County tend to rank in the second and third quartiles (average) for most categories of crime and domestic violence. Charlotte County ranks higher (first quartile) in most categories. Larceny rates were the highest crime indicator for Lee and Charlotte counties, while burglaries lead the crime indicators for Hendry County. Table 8: Crime and Domestic Violence 3-Year Rate per 100, Lee Charlotte Hendry State Rate Quartile* Rate Quartile Rate Quartile Rate Larceny 1, , , ,477.4 Burglary , Total Domestic Violence Offenses Aggravated Assault Motor Vehicle Theft Robbery Forcible Sex Offenses Murder Source: Florida Department of Law Enforcement *County compared to other Florida counties. The lowest Quartile equals the lowest number. Refer to the Social and Mental Health section of Appendices A (Lee), B (Charlotte), and C (Hendry) for larceny and burglary rates over time for each of these counties. 44

46 Alcohol-related Motor Vehicle Crashes In 2011 residents in Lee County, Charlotte County, and Hendry County were involved in a total of 5,997 motor vehicle traffic crashes, according to the Florida Department of Highway Safety and Motor Vehicles. Of these, 11.6 percent (697 crashes) were alcohol-related. In that same year there were 117 deaths due to motor vehicle traffic crashes; 28 percent (33 deaths) were alcohol-related. As shown in Chart 24, Lee County, with its larger population, accounted for the majority of these deaths. 250 Chart 23: Motor Vehicle Crash Deaths, in Lee, Charlotte, and Hendry Total Deaths and Alcohol-related Deaths, Motor Vehicle Crash Deaths Alcohol-related Motor Vehicle Traffic Crash Deaths 0 Source: Florida Department of Health, Bureau of Vital Statistics, and Florida Department of Highway Safety and Motor Vehicles Chart 24: Motor Vehicle Crash Deaths Total Deaths and Alcohol-related Deaths, Lee Charlotte Hendry Motor Vehicle Crash Deaths Alcohol-related Motor Vehicle Traffic Crash Deaths Source: Florida Department of Health, Bureau of Vital Statistics, and Florida Department of Highway Safety and Motor Vehicles 45

47 The percent of adults who reported on the Behavioral Risk Factor Surveillance System survey that they engage in heavy or binge drinking in Lee County is higher than the state average (18.1% Lee vs. 15.0% State). Charlotte and Hendry counties had lower rates of adults reporting that they engage in heavy or binge drinking than the state average. 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% Chart 25: Percentage of Adults who Engage in Heavy or Binge Drinking % 6.0% 4.0% 2.0% 0.0% 18.1% 12.3% 12.5% 15.0% Lee Charlotte Hendry State 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]. Refer to the Social and Mental Health section of Appendices A (Lee), B (Charlotte), and C (Hendry) for a detailed breakdown of this data by income for each of these counties. 46

48 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. 1,994 Lee County students completed the survey, 898 students in Charlotte County, and 1,028 students in Hendry County. Students were asked if they had consumed alcohol in the past thirty days. More middle school students in Hendry County reported that they had consumed alcohol in the past thirty days than their counterparts in Lee and Charlotte counties. Fewer Hendry County high school students reported having consumed alcohol than high school students in Lee and Charlotte counties. Overall rates of students who had consumed alcohol were highest in Charlotte County. The percentage of students reporting cigarette use over the past 30 days varies significantly among the three counties that Family Health Centers serves. Charlotte County had a much higher percentage of students, particularly high school students, who reported having used cigarettes in the past 30 days than students in Lee and Hendry counties and the state as a whole. Chart 26: Past 30-Day Use of Alcohol, Cigarettes, and Marijuana % 25.0% 20.0% 15.0% 10.0% 5.0% Lee Charlotte Hendry State 0.0% Alcohol Cigarettes Marijuana Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families The percentage of students reporting marijuana use over the past 30 days was highest in Charlotte County (16.5% of all students surveyed). Lee County had the lowest rates of marijuana use amongst middle school students (3.0%). Lee County high school students, however, had rates of marijuana use higher than the state average (20.9% Lee vs. 18.5% State). Refer to the Social and Mental Health section of Appendices A (Lee), B (Charlotte), and C (Hendry) for trends over time of usage of alcohol, cigarette, marijuana and various other drugs as well as lifetime use for these and other drugs, and differences between middle school and high school students. 47

49 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. Lee and Charlotte counties have had age-adjusted suicide rates above the state average for the last decade. Rates for suicide in Hendry County appear very sporadic, due to the small population size of the county. The actual number of suicides in Hendry County has been extremely low in recent years. In fact, in 2012, Hendry County had two suicides for a rate of 5.2 per 100,000 population, which was the lowest rate of all 67 counties in Florida for that year. Charlotte County had 35 suicides in 2012 for a rate of 23.2, which was the 7 th highest age-adjusted suicide rate of all 67 counties in Florida. 25 Chart 27: Age-Adjusted Suicide Death Rate 3-Year Rate per 100, Lee Charlotte Hendry State Source: Florida Department of Health, Bureau of Vital Statistics Chart 28: Total Suicides Lee Charlotte Hendry 2 Source: Florida Department of Health, Bureau of Vital Statistics 48

50 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). Since 2002, involuntary examinations have seen a steady increase across the state of Florida as a whole. Lee and Charlotte counties have seen a similar increase, while Hendry County s rates of involuntary examinations have seen a slightly downward trend. All three counties have consistently had rates of involuntary examinations much lower than the state average Chart 29: Involuntary Examinations* Single Year Rate per 100,000 Population Lee Charlotte Hendry State 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. 49

51 The number of involuntary examinations in a county that does not have a receiving facility is often lower than in a county that does have a receiving facility. Only about half of Florida s counties have a Baker Act receiving facility; Hendry County does not have a Baker Act receiving facility. 4,000 3,500 Chart 30: Involuntary Examinations* ,582 3,000 2,500 2,000 1,500 1, , Lee Charlotte Hendry Source: 2012 Florida Mental Health Act (The Baker Act) Report / 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. 50

52 Hospitalizations Prevention Quality Indicators 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 preventive 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 healthcare 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 D. Congestive heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease (this category includes chronic bronchitis and emphysema) are the most common preventable causes of hospitalization for the three counties that Family Health Centers serves Chart 31: Prevention Quality Indicators Rate per 100, Lee Charlotte Hendry State Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of Lee County, Charlotte County, and Hendry County residents in any hospital in Florida. 51

53 Table 9: Prevention Quality Indicators Rate per 100, Lee Charlotte Hendry State 01-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 Lee County, Charlotte County, and Hendry County residents in any hospital in Florida. Refer to the Hospitalizations section of Appendices A (Lee), B (Charlotte), and C (Hendry) for prevention quality indicator rates over time for each of these counties. 52

54 Chronic Conditions 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). Hypertension is the number one cause of hospitalization for a chronic condition for residents in Lee, Charlotte, and Hendry counties. In 2012 there were 46,777 hospitalizations due to hypertension, which is nearly the same number of hospitalizations for all other chronic conditions combined. 50,000 45,000 40,000 35,000 30,000 25,000 46,777 Chart 32: Hospitalizations for Chronic Conditions ,073 20,000 15,000 10,000 5, ,842 Hypertension Diabetes Congestive Heart Failure 7, Asthma AIDS Sickle Cell Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of Lee County, Charlotte County, and Hendry County residents in any hospital in Florida. Refer to the Hospitalizations section of Appendices A (Lee), B (Charlotte), and C (Hendry) for chronic conditions counts over time for each of these counties. 53

55 Emergency Room Visits Residents of Lee, Charlotte, and Hendry counties made 215,288 visits to hospitals in 2012 that did not result in an inpatient admission. The largest numbers of visits were made to Healthpark Medical Center and Lehigh Regional Medical Center. The next largest numbers of visits were made to Cape Coral Hospital, Gulf Coast Medical Center, Lee Memorial Hospital and Peace River Regional Medical Center. Over one-third (35.2%) of all emergency room visits were paid for by Medicaid, and one-fifth (20.3%) were paid for by Medicare. Table 10: Emergency Room Visits by Lee, Charlotte, and Hendry Residents by Payer Source 2012 Medicaid Medicare No charge/ Charity Other Private, incl. HMO Self- Pay* Grand Total Healthpark Medical Center 17,151 5,157 2,429 1,283 8,547 3,674 38,241 Lehigh Regional Medical Center 14,645 3, ,086 5,184 27,859 Cape Coral Hospital 7,018 6,369 1,798 1,302 5,370 3,265 25,122 Gulf Coast Medical Center 7,356 5, ,425 5,623 4,690 24,906 Lee Memorial Hospital 6,092 4,243 2,236 1,317 3,702 5,376 22,966 Peace River Regional Medical Center 6,786 2, ,734 2,250 14,811 Fawcett Memorial Hospital 2,581 5, ,508 1,749 13,110 Charlotte Regional Medical Center 3,188 3, ,904 1,595 10,682 Hendry Regional Medical Center 3,590 1, ,581 2,139 8,777 NCH Healthcare System North Naples Hospital 2,141 1, ,467 1,324 7,700 Englewood Community Hospital 1,324 2, , ,126 Sarasota Memorial Hospital 1, ,657 Glades General Hospital ,563 Physicians Regional Medical Center - Pine Ridge ,527 Venice Regional Medical Center ,056 Naples Community Hospital Physicians Regional Medical Center - Collier Blvd Palms West Hospital Desoto Memorial Hospital Total 75, % 43, % 8, % 10, % 42, % 35, % 215, % 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 Lee County, Charlotte County, and Hendry County 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 200 visits are included in the chart above. There are an additional 5,441 visits divided amongst 185 hospitals that have not been included in the chart, but are included in the total. 54

56 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 Lee County, Charlotte County, and Hendry County residents including the rate of uninsured residents, licensed providers and facilities, and federal health professional shortage designations. In 2010, 17.3 percent of adults in Florida 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. Residents in Family Health Centers service area reported rates higher than the state average. Residents were asked the same question in 2007 and showed lower rates than in Chart 33: Percentage of Adults Who Could Not See a Doctor at Least Once in the Past Year Due to Cost 2007 and % 25.0% 20.0% 15.0% 10.0% 15.7% 19.3% 13.3% 21.2% 24.2% 22.7% 17.3% 15.1% % 0.0% Lee Charlotte Hendry State 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]. Refer to the Health Resources section of Appendices A (Lee), B (Charlotte), and C (Hendry) for this data broken down by sex, and income for each of these counties. 55

57 Residents age 65 and older in all three counties, as well as the state as a whole, reported lower rates of cost affecting their ability to see a doctor in the past year, likely due to their access to Medicare benefits. In Lee County and particular in Charlotte County, adults ages 18 to 44 reported the highest rates of reporting that they could not see a doctor in the past year due to cost (33.6% Lee, 40.6% Charlotte). Hendry County saw slightly higher rates for those ages 45 to 64 (27.2% vs. 25.9% 18-44). Chart 34: Percentage of Adults Who Could Not See a Doctor at Least Once in the Past Year Due to Cost 2010 by Age 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% & Older All Adults 5.0% 0.0% Lee Charlotte Hendry State 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]. 56

58 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. Medicaid enrollment has steadily increased across the state of Florida over the last five years. Lee, Charlotte, and Hendry counties saw a similar increase during this time as well. Please note that due to the small size of Hendry County s population, a small number of cases can cause a large variance in the rate per 100, Chart 35: Median Monthly Medicaid Enrollment Single Year Rate per 100,000 Population Lee Charlotte Hendry State Source: Florida Department of Health, Office of Planning, Evaluation & Data Analysis 57

59 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 According to the Florida Healthy Kids Corporation, nine in ten children in the state of Florida have health insurance. Over the twelve month period from September, 2012 through August, 2013 the number of children enrolled in Florida Healthy Kids and MediKids has increased, while enrollment in the CMS Network has been on the decline. Table 11: Monthly Children s Health Insurance Enrollment Lee County, Charlotte County, and Hendry County combined Florida Healthy Kids MediKids CMS Total Active Children September, ,074 1, ,519 October, ,015 1, ,392 November, ,066 1, ,474 December, ,023 1, ,458 January, ,853 1, ,229 February, ,070 1, ,494 March, ,243 1, ,674 April, ,295 1, ,773 May, ,507 1, ,021 June, ,587 1, ,111 July, ,489 1, ,953 August, ,523 1, ,981 Source: Florida Health Kids Corporation 58

60 Overall enrollment in these health insurance programs has shown an increase from a low of 13,299 in January, 2013 to a high of 14,111 in June of the same year. 14,200 14,000 13,800 13,600 13,400 13,200 13,000 12,800 12,600 Chart 36: Total Monthly Children s Health Insurance Enrollment* Lee County, Charlotte County, and Hendry County combined 13,519 13,392 13,474 13,458 13,229 13,494 13,674 13,773 14,021 14,111 13,953 13,981 Source: Florida Healthy Kids Corporation * Florida Healthy Kids, MediKids, and CMS totals 59

61 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, Lee, Charlotte, and Hendry counties were estimated as having 30.4 percent of adults without health insurance; this compares to a rate of 29.3 percent for Florida as a whole. This number is a 3.5 percent decrease from 2006, but is on the rise after a low of 28.2 percent in % Chart 37: Uninsured Adults (Age 18-64) Lee County, Charlotte County, and Hendry County combined 31.0% 30.0% 29.0% 28.0% 27.0% State Combined 26.0% 25.0% 24.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) Table 12: Uninsured Adults (Age 18-64) 2011 Lee Charlotte Hendry Combined State Number Uninsured 107,646 20,444 9, ,809 3,342,845 Percent Uninsured 30.6% 25.5% 43.5% 30.4% 29.3% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) Refer to the Uninsured section of Appendices A (Lee), B (Charlotte), and C (Hendry) for this data broken down by income for each of these counties. 60

62 While the percentage of adults who are uninsured has seen an increase in recent years, Florida residents under the age of 19 have seen the opposite trend. Residents in Lee, Charlotte, and Hendry counties have slightly higher rates of uninsured youth, but those rates are also on the decline. 30.0% Chart 38: Uninsured Youth (Under 19 Years) Lee County, Charlotte County, and Hendry County combined 25.0% 20.0% 15.0% 10.0% State Combined 5.0% 0.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) Table 13: Uninsured Youth (Under 19 Years) 2011 Lee Charlotte Hendry Combined State Number Uninsured 17,823 2,955 1,983 22, ,442 Percent Uninsured 14.1% 12.7% 17.7% 14.1% 12.5% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) Refer to the Uninsured section of Appendices A (Lee), B (Charlotte), and C (Hendry) for this data broken down by income for each of these counties. 61

63 Physicians and Facilities As of 2011, there were one thousand eight hundred and ninety-seven licensed physicians in Lee, Charlotte, and Hendry counties. That works out to approximately 229 doctors for every 100,000 residents. That is a lower rate than the state average of 342 doctors for every 100,000 residents. In fact, the rates of all providers in these counties are lower than the state rates. The rates per 100,000 residents for hospital beds, acute care beds, and specialty beds are all lower than the state rates. However, the rate of skilled nursing home beds in Lee, Charlotte, and Hendry counties is per 100,000, which is slightly higher than the state rate of Providers* Table 14: Health Resources Availability 2011 Lee County, Charlotte County, and Hendry County combined Rate per Number 100,000 State Rate per 100,000 Total Licensed Dentists Total Licensed Physicians 1, Total Licensed Family Private Practice Physicians Total Licensed Internists Total Licensed OB/GYN Total Licensed Pediatricians Facilities Total Hospital Beds 2, Total Acute Care Beds 2, Total Specialty Beds Total Skilled Nursing Home Beds 3, County Health Department County Health Department Full-Time Employees County Health Department Expenditures $26,949,994 $3,258,778 $4,204,339 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. Refer to the Physicians and Facilities section of Appendices A (Lee), B (Charlotte), and C (Hendry) for a detailed breakdown of this data for each of these counties. 62

64 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 / Medically 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. Any population with a score of 65 or lower on the Index of Medical Underservice is considered medically underserved. Lee County s Low Income/Migrant Farmworker Populations have been designated as Medically Underserved Populations. Lee County s Low Income/Migrant Farmworker Populations scored a Charlotte County s Low Income Population has been designated as a Medically Underserved Population. Charlotte County s Low Income Population scored a Hendry County s Low Income/Migrant Farmworker Populations in LaBelle have been designated as Medically Underserved Populations. LaBelle s Low Income/Migrant Farmworker Populations scored a Health Professional Shortage Areas 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. 63

65 Lee County has been designated as a Health Professional Shortage Area (HPSA) for primary care for low income populations in Fort Myers, Lehigh Acres, North Fort Myers, Bonita Springs and Cypress Lakes. Bonita Springs, Fort Myers, North Fort Myers and Lehigh Acres were designated as Health Professional Shortage Areas for dental care for low income populations as well. Charlotte County has been designated as a Health Professional Shortage Area (HPSA) for primary care at the Charlotte County Health Department and the Charlotte Correctional Institution, as well as for the low income population in Port Charlotte and Punta Gorda. Charlotte Correctional Institute and the low income population in Port Charlotte were designated as Health Professional Shortage Areas for dental care. Hendry County has been designated as a Health Professional Shortage Area (HPSA) for primary care. Hendry Correctional Institution and Big Cypress Indian Health Service Area were listed specifically as HPSAs for primary care in the county. Hendry County was designated as a Health Professional Shortage Area for dental care, including specific designations at the Big Cypress Indian Health Service Center and for the low income and migrant farmworker populations. The Glades/ Hendry Catchment area has been designated as having a shortage of two mental health professionals. 64

66 Community Input Survey on Health and Healthcare in Lee, Charlotte, and Hendry counties The Health Planning Council of Southwest Florida, with feedback from the Family Health Centers of Southwest Florida s Community Health Assessment Committee, developed a survey questionnaire to assess residents perceptions of healthcare and health issues for Family Health Centers service area. The survey was conducted online and on paper, in both English and Spanish. Surveys were distributed by members of the s Community Health Assessment Committee to those who live and/or work in Lee County, Charlotte County, and Hendry County. Links to the online version of the survey were distributed through flyers and blasts. The English version of the survey is included in Appendix E. 264 surveys were completed on paper and online over a three month period at the end of 2013 (248 in English, 16 in Spanish). 98 percent of survey respondents were permanent residents, 1 percent were seasonal and 1 percent were temporary residents. Twenty-nine percent reported living in a Fort Myers zip code; 23 percent reported living in a Cape Coral zip code; 13 percent reported living in a North Fort Myers zip code, and 8 percent reported living in a Port Charlotte zip code. The survey garnered responses from a slightly higher proportion of respondents ages 35 to 64 than in the overall adult population in the service area (63% of survey respondents vs. 38% of adults in that age range in the service area). There were also more females who responded to the survey than in the adult population in the service area (80% of survey respondents were female vs. 51% of adults in the service area). Race was evenly distributed, with 87 percent of survey respondents being white (88% in the overall population), 8 percent of respondents were black (9% in the overall population) and 5 percent were other (3% in the overall population). The surveys were completed by a slightly higher proportion of Hispanic residents than in the overall population (21% of the survey respondents identified as Hispanic vs. 18% in the overall population). Of those who responded to the survey, the majority (54.4%) reported having private health insurance, and 19.9 percent reported being uninsured. (Please note, respondents were allowed to select multiple answers for the majority of the questions asked.) 65

67 What type of insurance do you have?* Private insurance (through employer) % None % Medicare % Veteran % Private insurance (self-pay) % Other** % Medicaid 5 2.1% *totals to more than 100% as some respondents selected multiple options ** fluxuates., Storywell, only my 18 yr daughter has Medipass. Parents were dropped from Med.Needy due to youngest turning 18. I have medical problems and can't go to drs now., AARP/United, MC Supplement I pay, Mutual of Omaha, United Health Care, Through my husbands insurance policy, only recently acquired coverage, Denied due to pre exisiting condition, TFL, my son has FL kidcare. 25 percent of survey respondents ages 18 to 34 reported having no health insurance. Of those ages 35 to 64, 20 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 Family Health Centers of Southwest Florida.) When asked, How would you rate the general health of residents in your county? 6 percent of survey respondents said Excellent, 48 percent said Good, 43 percent said Fair, and 4 percent said Poor. When asked, How would you rate the quality of healthcare in your county? 13 percent said Excellent, 48 percent said Good, 28 percent said Fair, and 10 percent said Poor. Survey respondents were asked if they received healthcare services at Family Health Centers of Southwest Florida. 32 percent of respondents said they do. When asked where they go to receive healthcare services (for those who do not receive services at Family Health Centers), the majority said they visit their family doctor (55.5% of respondents who do not receive services at Family Health Centers) or a specialty doctor (13.3% of respondents who do not receive services at Family Health Centers). Of those survey respondents who reported having no health insurance, 19 percent reported going to a health department for healthcare (2 respondents from Charlotte County and 7 respondents from Cape Coral) and another 19 percent reported going to a hospital or emergency room for healthcare. 66

68 Do you receive healthcare services at Family Health Centers of Southwest Florida? Where do you go to get healthcare? (If not at Family Health Centers.) family doctor 55.5% No 68% specialty doctor 13.3% Yes* 32% hospital/emergency room 11.4% * If yes, which location: (25 respondents) Port Charlotte, (10) St. James City/Pine Island, (7) Grand Ave, (5) Fort Myers, (4) Health Park, (4) Children's Hospital, and Lee Memorial, Children's Oncology, Lee Physician Group, Florida Community Health Centers, Bonita Springs, Bass Road, Women's Health Center, Homeless Outreach, First Baptist, Palm Beach Blvd, LaBelle, Cape Coral and Family Center. health department 7.6% urgent care center 6.1% other* 3.8% don't know 1.1% out of state/out of area 1.1% * Cape Coral, VA Clinic, employer's own clinic, I don't have a family doctor. (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.) 67

69 Respondents were asked their opinions on healthcare difficulties for specific populations in their county. Of the population groups listed, those who are uninsured and have low income levels were selected most often (133 responses). The next most frequently chosen option was working low-to-middle income residents (94 responses). What types of residents of your county have more difficulty with healthcare than others? uninsured/low-income 133 working low-to-middle income 94 migrants 66 elderly/senior citizens 66 non-english speaking 63 persons on Medicaid 47 adults 46 persons with disabilities 33 children 20 veterans 18 teens/adolescents 12 other* 9 none 2 * Don t know, No idea, everyone, homeless, All types fit this question, No one should have difficulty with healthcare, Veterans who are dishonorably discharged - no VA benefits - they fall through the cracks. 68

70 With regards to specific areas of the county where residents are thought to have a particularly difficult time accessing healthcare services, 79 respondents said there are none. 160 respondents named multiple locations in the area as having difficulty accessing health services. The areas with the most responses listed were Lehigh Acres (37 responses), LaBelle (29 responses), and Cape Coral (28 responses). Are there areas/neighborhoods where residents have a particularly difficult time accessing health services? no 79 yes* 160 Lehigh Acres 37 LaBelle 29 Cape Coral 28 East Fort Myers/Dunbar 26 Pine Manor 25 North Fort Myers 23 Fort Myers 21 Yes, Suncoast Estates 21 Alva 19 Pine Island 12 Port Charlotte 12 Bonita Springs 11 Other* 79 * Charleston Park, San Carlos Park/Three Oaks, Estero, Palmona Park, South Fort Myers, Cleveland, Page Park, Englewood East/Cape Haze, Grove City/Rotunda West/Placida/Boca Grande, West Port Charlotte, Fort Myers Shores, Gateway, Sanibel/Captiva, Murdock, Punta Gorda, Deep Creek, Harbour Heights, Immokalee, North Naples, Areas with no or limited access to public transportation, Clewiston, accessing may not be so much of an issue as payment, don't know, I have no idea, the most very rural area of Hendry Co not listed, The lower to middle class working poor seem to be well distributed throughout the county., Cant answer with certainty, All areas have a hard time accessing health services, I only have knowledge of the areas I have checked., Not sure what is available by area, I don't know, any location for Seniors who need transportation, County wide issues, Only know about my area-pine Island, I don't know., Moore Haven, Clewiston, All of Charlotte County. 69

71 The surveys also asked about difficulties in receiving specific types of health services. Fifty-one respondents said, no, there are no services that individuals in the service area have difficulty accessing. Of those who felt there were services that were difficult to access, dental care for adults was number one, with 98 responses. Next highest on the list was mental health care for adults, with 75 responses and dental care for children 59 responses). Chart 39 Are there services that individuals in that area/those areas have difficulty accessing? dental care (for adults) mental health care (for adults) dental care (for children) mental health care (for children) primary care substance abuse treatment specialty care medications/pharmacy preventive care hospital care maternity/prenatal care pediatric care emergency care other* Community Health Assessment - Family Health Centers 2014 *other: Don't know, Pediatric in home health care, Pediatric specific: physical therapy, occupational therapy, Speech therapy, Feeding therapy, do not know, bus, Specialty care for pedicatrics., Most Services are available in the county, getting there and paying for it is the main issue, All care is difficult for the lower to middle class working poor., Eye care, Not sure what is available by service, I don't know, I'm sure most of them. 70

72 Possible options for improving the health of area residents were given. Financial assistance for health care was chosen most often by survey respondents, with 114 responses. The next highest options were job opportunities (107 responses) and counseling and support groups (94 responses). Chart 40 What does your county need to improve the health of your family, friends, and neighbors? financial assistance for health care job opportunities counseling & support groups mental health services transportation additional health services health education healthier food choices after-school/out-of-school programs more doctors bicycle paths/walking paths substance abuse treatment services wellness programs specialty doctors recreational facilities (parks, sports fields, etc.) safer environment other* Community Health Assessment - Family Health Centers 2014 *other: Tutoring programs, Medipass providers and Medicaid HMO s, In home health care pediatrics, Good and concerned family practitioners, subsidize fruits/veggies, cheaper health care programs, Healthy families, classes on marriage & parenting., Doctors willing to take uninsured clients, some doctors offices need to have longer hours. so we don't have to take our kids out of school for their appts., Health Insurance, Financial assistance for medication. 71

73 Respondents were asked to select what they felt to be the three most important health concerns for residents of their county. Access to primary care topped the list, with 109 responses. Second highest on the list was access to specialty care, with 92 responses, followed by mental health problems (71 responses) and cancer with 57 responses. Chart 41 Which of the following do you feel are the three most important health concerns in your county? *other: Special needs/situations for very ill unable to care for self, doctors insurance gives us are in SeaBreeze and Clewiston, Cost of doctor's visits, The waiting for the phone to be answered, It's impossible to call for my appointment., No idea, lack of pediatric doctors and dentists who accept medicaid/healthy kids, lack of insurancepeople not being treated when ill., Skicell Anemia, smoking, A lack of providers who accept FL Medicaid/Medicare, Lack of parenting skills, Good primary care for Medicaid children', children's lack of good nutrition, mental health care for children, Transportation to doctor's offices and therapy centers., Lack of education, Cost associated with health care, To many doctors who are quick to put you on pills. Doctors not knowing their patients like when my wife had her thyroid removed and the doctor forgot she had the surgery., Health and Dental care for the low income/not qualified for Medicate, pricing and the amount you pay for care, Cost of medical care, Access to health insurance, Lack of medical service to the homeless. 72

74 Respondents were then asked to select the three most important risky behaviors in their county. Substance abuse was listed most frequently, with 131 responses, and being overweight was a close second with 124 responses. Other risky behaviors identified included smoking/tobacco use (95 responses), distracted driving (94 responses), lack of exercise (78 responses), and poor eating habits (73 responses). Chart 42 Which of the following are the three most important risky behaviors in your county? *other: Equality in receiving top notch doctors, No idea, Low community engagement in productive activities, talking on phone, drunk driving, using cel phones and texting while driving, JAYWALKING! Lack of safety consciousness and consideration for others. 73

75 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 in their county from seeking medical treatment. A lack of health insurance and/or lack of ability to pay was cited most frequently (214 responses). The next most often cited reason for delaying treatment was transportation (65 responses), and lack of knowledge/understanding of need (62 responses). Chart 43 What do you think is the main reason that keeps people in your county from seeking medical treatment? *other: They are not American Citizens and fear deportation, Cost associated with health care, No money to pay for services, cost of medication, Lack of personal responsibility, The Charlotte County Helath Dept no longer providing primary care, lack of speciality services, only see limited doctors none of which I need, A lot of adult doctors don't accept Medicaid., No idea. 74

76 Survey respondents were given the opportunity to offer additional comments on health and healthcare in their county. Some general themes to these comments were the need for more doctors and more Medicaid providers in the county, and options for residents who do not have health insurance. *Listed below are comments added by residents of the service area who completed the Survey on Health and Healthcare. 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. Need for specific doctors. My insurance wants me to travel two hours each way to see specialist. more places that accept Medicaid so the wait isn't hours long It takes over 4 hours to get in to see a doctor. There is only place in town to see a primary care doctor if you have no insurance. There is no preventative dental programs for adults. We the patients have to wait more than 4 hours to get attended to. Dental services for adults with medicaid need to improve and include at least one yearly checkup. We need more doctors who will except Medicaid. People wait too long for a doctor because there's not much of a selection. Need more specialty doctors that take medicaid Charlotte needs to approve patients who have medicare but can't afford to pay the 20%. I for example can't get medicaid as a secondary when I know I qualify I keep getting denied don't understand. Low income/no insurance residents have little-to-no choices for primary care! It takes too long waiting for your appt. with the Dr. but I am greatful she is my doctor + I can come here + Thank God that I can afford it. Nothing, because most people's lives do not revolve around healthcare. If you have no job/income, the only health care option is the emergency room! Most have trouble getting Dental care help and for health services. There are some things that they are not willing to help with. (Payment plans) should be something to consider. There are many people over 21 to 50 without children that are unemployed and/or under-employed due to too many part-time jobs. Without a Medicaid expansion or allowing families of 3-4 making less than 11,500-23,500 to receive lower premiums, we might be exempt of a penalty but we will still be stuck with not being able to have any health insurance or not be able to afford it. Sorry for bad sentence structure. interpreters in local doctors' offices We need all of this! More doctors and nurses. 75

77 Interviews with Community Leaders Introduction The Health Planning Council of Southwest Florida (HPC) conducted thirty-three key informant interviews in 2013 and early 2014 with the cooperation of. The purpose of conducting the interviews was to better understand the perspectives of key community leaders on the health and healthcare needs of Lee County, Charlotte County, and Hendry County 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 these counties, which encompass Family Health Centers service area. The findings provide qualitative information and reveal factors affecting the views and sentiments regarding healthcare services in the service area. A summary of community leaders opinions is reported without judging the veracity of their comments. Key Interview Findings There are felt to be many healthcare services available in the area, however, residents are not completely aware of the options that are available to them. There are felt to be some shortages in services available for those who have Medicaid and for those without health insurance. Leaders suggested there is a need for an increase in preventive care outreach and preventive care services. Services specifically mentioned as being difficult to access were transportation and specialty services. There is felt to be a need for more mental healthcare providers. The number one health issue identified by most interviewees is education education on the services that are available in the area as well as education on healthy living. 76

78 Methodology A community committee created by (Community Health Assessment Committee) compiled a list of possible interview subjects. 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. Thirty-three key community leaders were interviewed at the place of their employment or another location of their choosing in mid-to-late 2013 and early 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 the service area; 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. 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 Lee Memorial Vision Group, Family Health Centers Board, Florida Department of Health in Charlotte County's CHIP Steering Committee, Florida Department of Health in Charlotte County's Access to Care Committee, Lee County Early Head Start Board, Island Coast Primary Care Network Board, SalusCare Planning Committee, Association of Nurses, and the Advisory Council for Healthy Families. The length of time that the community leaders have lived and/or worked in southwest Florida ranges from two years to forty-five years. The average number of years that an interviewee has lived or worked in southwest Florida is nineteen 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. 77

79 General Perceptions When asked to share their impressions about health and healthcare in the service area, community leaders spoke at length about the assets and deficiencies of the system. Eight respondents felt strongly that there are many healthcare options available in the area. One respondent noted, Access to primary care and specialty care is good, especially in Lee County. Another stated that there have recently been new doctors recruited to the area, which leads to, better access to care for area residents. The issue for many respondents, however, is that there are limited options for those on Medicaid, or for those without insurance. The healthcare options are good, but working families without Medicaid or good insurance are challenged, as they have somewhat limited options, stated one community leader. This sentiment was echoed by another leader who stated, There is very little available for low-income without Medicaid in Charlotte County. Another respondent felt that even for those with Medicaid there are a limited number of primary care doctors who will see them for care. Six respondents stated that there are limited options for specialty care in the service area. One interviewee stated, It is very difficult for some populations to get specialty services, like certain dental procedures, certain cancer specialists. Another stated of healthcare in Hendry County, Pediatric coverage is adequate, but we lack specialists. One community leader stated similarly that, a lot of Hendry and Charlotte County residents go to Lee or to the other coast, for healthcare services. Four community leaders stated that they believe that the issue isn t that there are limited options, but that there is not enough awareness of the options that are available. One of these four stated, There are plenty of options, but the population isn t educated about them. Hispanics, homeless, and residents who are considered extremely low income were felt to be particularly lacking in information about services available to them. One leader said that there are some services available to middle and lower income classes, but homeless and extremely low income are not aware of these as much as they could be. Another stated that, the Hispanic community doesn t have a lot of education on resources available to them. Three community leaders stated that the area has good general health. Two felt that the general health of area residents is average, and four felt that the general health is fairly poor. Three interview respondents described the low-income population as having poorer health than those with higher incomes. One interviewee stated that, people want to have more prevention, but with poor economy they eat what they can find. When asked what they felt were the essential components of a quality healthcare system, the majority felt that having plenty of provider options and ease of access were the keys. One community leader stated, The components are ERs, hospitals, primary care, and specialists for acute problems. Must reach all of the community home health, long term care, decent public transportation. Lee County is on its way. Hendry and Charlotte are lacking. Another community leader stated that as far as options, These programs are currently in Lee County and Charlotte County, but access is difficult for the uninsured and underinsured. Five interviewees felt that coordination among healthcare providers was the main component of a quality healthcare system. One community leader stated, Should have clinical integration and coordinated care. There are areas where places compete unnecessarily and duplicate care not efficient. Another stated that we need to work on, Communication between EMRs (electronic medical records); remove roadblocks and duplications. 78

80 Pressing Healthcare Needs The community leaders were asked to identify the most pressing healthcare needs in the service area. The most common responses were accessibility (nine respondents), dental care, especially pediatric dental (seven respondents), and specialty care (six respondents). Four interviewees believed that preventive care is the most pressing healthcare need in the area. One community leader stated that, routine health visits are a luxury to the poor. Affordability, including healthcare as well as prescription medications, was also mentioned by some of the interviewees. One interviewee suggested that, we need to see more sliding fee scales. There are fairly good free screenings available. It would be nice to see more of those. Other healthcare needs mentioned by interviewees included education on available healthcare options, general surgery, healthy lifestyle education, mental health services, pediatric services, and substance abuse treatment. Issues Affecting Specific Groups Community leaders were asked to give their opinion on issues impacting particular groups of the service area residents. Those groups included children, teen/adolescents, adults, the elderly, the uninsured, homeless and migrants. Children Ten community leaders suggested that obesity was the most pressing health issue for children, and similarly, four others suggested that nutrition was the most pressing issue. It was stated by one interviewee that, their diet is not good. Eight interviewees felt that preventive care was the most pressing health issue for area children. One interviewee stated that the area need more prevention programs, while others felt there are programs available that are not being utilized, specifically routine well-child checks and scheduled vaccinations. Other issues cited were dental care, mental health care, lack of health insurance and specialty care. Teens/Adolescents Teens and adolescents present a different list of healthcare needs. It was widely stated that there is a need for further sex education as well as more mental health services for this population. One community leader stated that Lee Mental Health is fabulous. Only does crisis management, though. Another leader agreed that there is hardly any mental health for kids that age. Several of the interviewed leaders stated that there is a need for a substance abuse prevention and treatment program for teens. Other issues mentioned included obesity, health information, and a focus on teenagers taking charge of their own health. Adults For adults, issues related to chronic diseases were the most often mentioned pressing health concerns. Chronic conditions, such as obesity and diabetes were listed by several interviewees as major health issues, particularly in Hendry County. Five interviewees felt that education on healthy lifestyles was the most pressing health issue for adults. One community leader felt that the working poor and homeless in particular, tend to have less of a healthy lifestyle. Another five interviewees noted that a lack of 79

81 health insurance among adults was a pressing health concern in the service area. No Healthy Kids or Medicare for this age group. Take low wage jobs without health insurance, noted one community leader. Four respondents noted that nutrition is an issue for area adults. I think it all comes down to a missing link on nutrition, stated one interviewee. Another four respondents stated that preventive care was a pressing health issue for adults, nothing that many residents don t access available preventive care services because they are, complacent. Four respondents stated that affordability was an issue for adults, and another four respondents felt the overuse of the area emergency rooms was a primary concern. Also noted were delay of necessary treatment when ill, hypertension, access to specialty care, substance abuse, dental care, education on available healthcare options, lack of exercise, mental health issues, and obesity. Elderly The elderly generally have access to care through Medicare and so are typically considered to be in a better situation than many others. However, the elderly do still have pressing health issues. Those most commonly mentioned among community leaders were chronic medical conditions, having support, and transportation. Diabetes was the more frequently mentioned chronic condition that elderly residents are dealing with. Support for the elderly included assistance in clarifying health issue to their doctor, social isolation, and not placing people in nursing homes prematurely. One interviewee stated, It s more cost-effective and more dignified for people to remain in their homes. Affordability due to fixed incomes and access to specialty care, particularly during season, were listed by several interviewees as pressing health concerns as well. Also mentioned were Alzheimer s disease, dental care, kidney problems, neglect in nursing homes, and substance abuse. Uninsured When discussing the uninsured in the service area, the most common healthcare issue mentioned was access to primary care. One interviewee stated, Nowhere to send people for treatment. Even Family Health Centers doesn t offer sliding scale anymore. Mentioned nearly as frequently as access to primary care for the uninsured, was the overuse of area emergency rooms. One community leader stated, They have been incentivized to use reactive care. Another stated that they, spend money on children but neglect own health then go to ER. Five community leaders felt that affordability was a major health issue for the area s uninsured residents. According to one interviewee, the uninsured are, already scraping money together for food, utilities, etc. Have to make a choice on where to put money. Interviewees were also concerned about uninsured residents choosing to delay treatment, lacking follow-up care, needing healthy lifestyle education, access to specialty care, and uninsured illegals not getting care, due to fear of deportation. Homeless Six community leaders felt that the homeless in the area don t have any particularly pressing health issues, and that services are available to them. One community leader stated that, outreach from Family Health Centers lets homeless be seen regularly for basic needs like cold and cough. Another noted that, shelters offer clinics about once a year. 80

82 Five community leaders felt that access to care was the most pressing health issue for the area homeless population. One community leader stated that there is, nothing available for them. People don t like homeless; prefer not to think about them. Four interviewees believe that this is a particularly fragile population. They are at a, high risk for everything, stated one interviewee. Another stated that, cold or flu could put them in a hospital. Spider bites don t treat promptly; can lead to huge problem later. Several community leaders mentioned dental care, mental health, and substance abuse as pressing issues for the homeless population. Other issues mentioned were delaying treatment, overuse of emergency rooms, the cost of medications, preventive care, and vision services. Migrants When asked about the most pressing health issue for the migrant population in the area, the most frequent responses were fear of being deported due to their legal status and language barriers. Other frequently mentioned health issues were access to care, working in dangerous environments, and lack of awareness of healthcare options. Three community leaders stated that there are services available. One leader stated, In recent years employers have been providing more access to healthcare. Another noted that things are improving, Very bad, but used to be worse. There are some organizations that help. More are aware of migrants than the homeless. Other issues mentioned were affordability, cultural barriers, lack of health insurance, and not receiving preventive care. One leader suggested that providers should go to where the migrant camps and provide services to them there. 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 uninsured residents have difficulty accessing care due to inability to pay and lack of knowledge about where they can go to receive services. It was noted by one respondent, The perception is that there are dedicated services for these individuals, but there may be small pockets of services. Five community leaders stated that elderly residents have a particularly difficult time accessing services. Affordability and transportation were the main barriers that the elderly are thought to experience. One community leader noted, Seniors who live in the outskirt areas that are far away from access to care Lehigh, LaBelle have fewer access points to healthcare. Need information, mobile access; push the doctors out to those areas. Five community leaders named low-income residents as having difficulty accessing healthcare services. One interviewee stated, Outreach and education is the first step. Many aren t aware of options. They are scared of flu shots. Need medical/healthcare education. Another interviewee stated, Lower socio-economic classes have less money. Just above Medicaid, but not enough to pay. And there are those with some coverage but are at risk for financial debt. Other groups specifically mentioned as having difficulty with accessing care in the service area were minorities (Hispanics, migrants, Guatemalans, Mexicans), the homeless population, children, and those who receive Medicaid. 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. 81

83 Primary Care Nine community leaders stated that primary care services are available. One interviewee stated, It is available, people just need to know about it. Another noted, It s available. Wait times are long in season. Several others felt that while available, there were significant obstacles for some population groups. One leader stated, It exists but it is selective, based on what insurance you have. It s easier when people pay cash. Another stated, I think it s available but it s not serving all of the people looking for help because of transportation, etc. Another leader felt that, the issue is the adequacy of the number of providers. Not enough providers for the uninsured. Others felt strongly that primary care is not available. One leader stated, Not available at all. Not enough providers. Don t reach all of the rural areas. Not enough take Medicaid or other insurances. Transportation is a problem in Hendry and Charlotte counties. Another stated, We are missing care for the people who are uninsured and underinsured and illegals (undocumented residents). Preventive Care The community leaders interviewed were divided on the availability of preventive care in the service area. Eleven leaders felt that education is crucial, including education on the benefits of routine preventive care as well as education on what services are available. One leader stated, Lack of information prevents access. Similarly, another leader stated that some residents, wait until they get sick because they don t think they can afford it. But clinics and health departments are readily available. Seven interviewees believed that preventive care is available in the service area. One leader felt that preventive care is, fairly readily available. It s more of a cultural issue not part of some people s behavior. Another stated, There s a lot of effort for preventive care, especially through the health department and the county. What are we giving people for incentive to do preventive care? That s the key to prevention. Some community leaders felt that preventive care needs improvement. Access could be better. Quality is good, stated one leader. Another stated, Failing. Should focus more on prevention. We are constantly playing catch-up. For some leaders, income level is a factor as well. One leader stated that there is a, lack of convenient care for low-income. What s available is good quality, just not enough of it. Another stated that preventive care is, available if they can pay. For poor, they can t pay. Pediatric Care When discussing the availability of pediatric care in the service area, while many leaders felt the care is available and good quality, not all agreed. One respondent stated that children are, a population people care about. Another stated that, pediatric primary is fine; there are deficits in specialty. Has improved a lot, but there are still gaps. Mental health, for example. And another stated, It s good. The moms just have to wait a long time in the office. Others echoed the belief that wait times can be long. It s adequate. Some private providers don t want to take Medicaid. Family Health Centers of Southwest Florida has long waits. Often use urgent care or ER because of waits, stated one interviewee. Another stated, Must pay to go to Family Health Centers. Sometimes people can t even pay that. Line is long for free services. Other felt that those who are uninsured often have more difficulty accessing pediatric care, as well as those who are on Medicaid. It was suggested that there is a need for more pediatricians who are bilingual as well as more pediatric dental providers. 82

84 Dental Care The community leaders interviewed were divided on the availability of dental care in the service area. One leader stated, It is available. Awareness is needed. Family Health Centers offers services, plus other dentists. Another stated, Quality is good. Access is good. Conversely, one interviewee stated, Poor availability. Uninsured have complete lack of access. Abscesses are one of the top reasons for patients going to the hospital. And another stated, For indigents there is nothing. Moderate quality for what is available. Several community leaders felt the main issue with access to dental care in the service area is the expense. One leader in Lee County stated, It s expensive. For those who qualify health department. College does teeth cleanings and exams, but it is difficult to get an appointment. Another stated that, Most Hispanics fly to their country. Too expensive here. More costly than medical care. The cost to have dental insurance was felt to be equally prohibitive to residents. One community leader noted, Dental insurance is rare. Still too expensive. And Medicaid would rather pull teeth than fix them and then health suffers. Specialty Care Twelve community leaders stated that specialty care options in the area are limited. We could use more. I d like to see Fort Myers grow and become that bigger city like Miami, stated one interviewee. Another stated that specialty care options in, Hendry and Charlotte are limited. Another community leader stated, The United Way has provided We Care to provide charity care. The question is quantity. Others felt strongly that specialty care is adequately available in the service area. For seniors, geriatric, and skin cancer we are at the top of our game here. People come from all over, stated one community leader. One Charlotte County leader stated, Charlotte County has fairly good specialty care options. And another stated that, Lee has quite a variety if you have insurance. Hendry County leaders felt that there are no specialty options at all. Interviewees stated, We don t have any, No specialists for children at all, and None, when asked about specialty care in Hendry County. Lack of health insurance can be a hindrance in having access to specialty care providers. One interviewee stated, For insured it is pretty good. For uninsured can t access. For Medicaid it is limited but accessible. Mental Healthcare The majority of community leaders felt that mental healthcare is lacking in the service area. Thirteen community leaders stated that there is a need for more mental health providers. One leader stated, We really struggle with the numbers of people needing mental healthcare. It s a challenge. Another stated, There are a lot who should go but can t afford it. People don t know how to get in to the system. Not that many providers. And another stated, We need it. They just keep cutting benefits (at mental healthcare facilities). Big need for homeless. There s no state funding for it. Three interviewees specifically stated that mental healthcare is expensive. One interviewee stated, Copays per appointment are so high even with insurance. Another stated, Very restricted. Very expensive. Six leaders felt that mental healthcare is available throughout the service area. One leader stated, It is out there, but perception is that it is not out there. Adequate but people don t know how to access. Another stated, Charlotte Behavioral Healthcare and Coastal are available in Charlotte County. Hendry County residents feel there is availability of mental healthcare as well, stating, We have it, 83

85 There is a facility here, and Hendry/Glades Mental Health is it. Accept Medicare and Medicaid; sliding scale. Easy access. For those who felt that mental health services are available, four noted that the care available is good quality. One respondent stated, I am very happy with mental healthcare. SalusCare has SOARs program. Very happy. Another stated that mental healthcare in Lee County is, improving. Used to be really bad. (We have) Park Royal, SalusCare, and Lee Outpatient Mental Health. And another felt that while, there s need for expanded mental healthcare, we have high quality mental health services. Substance Abuse Treatment Eleven interviewees stated that substance abuse treatment is available. One community leader stated, There are some places in Lee, also in Hendry. Another stated, SWFAS does a great job but needs more funding. Of those eleven, however, seven felt that the available services are underutilized. One respondent stated, We have a problem in Charlotte County, but people don t utilize available options. Coastal has a juvenile program that is underutilized. Charlotte Behavioral has an adult detox program that is underutilized. Another interviewee stated, The big challenge is getting people to recognize when they need help. Five interviewees believe cost to be a barrier to accessing needed substance abuse treatment. One interviewee stated that, Real good substance abuse care is way too expensive. Prevention would be more important. Five interviewees stated that substance abuse treatment lacking. One community leader stated, Deficiency especially for adolescents. Park Royal is great, but only for adults. No detox for children. Another stated, Capacity is inadequate. Need more funding for early intervention. Emergency Care Emergency care options in the service area are available at the area hospitals as well as urgent care centers. Interviewees felt that emergency care in the county was very good, and good and swift. Others stated, Lee County has many locations. Hendry long way to go if having a heart attack, and, That s probably one of the more level playing fields in Lee County. The time of year a resident needs to use emergency services can make a difference, according to two interviewees. One stated, Long wait times in season. The other stated, Strong, except in season* - waits. (*Season refers to the winter months when the population swells with temporary and seasonal residents.) Overall availability of emergency care in the service area was felt by many to be adequate. Ten community leaders felt that emergency care is available. In Charlotte County, one leader stated, I think we have a lot of options for emergency. Three hospitals is a lot for such a small county. A Lee County interviewee stated, Access is good. Ambulances get you right there. Quality is good. Emergency room s care. Preferred the downtown Lee ER over Cape Coral. A few leaders felt that the emergency rooms are overused. One leader stated that the available emergency care in the area is, overburdened. Too many people using for primary care. Another stated that they are, over-utilized but available. They must see everyone, but it is too expensive to treat in ER. They could decrease use by percent if people had to pay to be seen. Hospital Care 84

86 The level of hospital care in general (non-emergency) in the service area was thought by most interviewees to be good. Comments included, excellent, except for season, strong, very good, I m blown away by the level of care, and frankly, I ve been impressed by hospital care. A few respondents were not as positive, stating the following, There s a rush to get people out. For the elderly, ends up with more readmissions, Billing department sucks. Bill under wrong patient, etc. Not very prompt, and There is no coordination whatsoever. It s really poorly coordinated. It was noted by two interviewees that follow-up care needs improvement. Hospice Care The area s hospice care received overall positive reviews. Comments included Hope Hospice is a great organization, Spectacular. I love them. Beautiful, peaceful, We have a great program Tidewell. They provide grief counseling and do a great job (Charlotte County), Lee County has a good rep. Very professional. Nice pediatric hospice program, and, We have Hope Healthcare Services. Love it. All good things to say (Hendry County). One interviewee suggested that the availability of more grief counseling would be beneficial. Another stated that they were frustrated by the practice toward the end of life of asking patients and their families, to donate their assets to hospice. This is a poor time; not a good place to be making the decision. It was also felt that hospice services are sometimes underutilized. One interviewee noted, Hispanics aren t used to using hospice care cultural barrier used to staying with extended family. Obstetrics/Gynecology and Maternity Care Resources for obstetrics/gynecology and maternity care in the service area were felt to be available, and felt by many to be of good quality. One interviewee suggested that the area need, more information and more services available in other languages. Another community leader echoed this with the comment that there are, not too many bilingual (providers). While options for ob/gyn and maternity care were generally felt to be available, it was noted that if a woman is not already an established patient, she may have a long wait to get an appointment, and that those who have Medicaid or are uninsured have limited options. Services Which Are Difficult to Access Community leaders were asked if there were services that individuals had difficulty accessing. Transportation and specialty services were listed most frequently. Other services that area residents have difficulty accessing include dental care, mental health services, rehabilitative services, particularly for the uninsured, and vision services. According to the interviewed leaders, specialty services, including rheumatology, gastroenterology, audiology, dermatology and orthopedics, are the services most often requiring residents to be referred outside the county. A lack of Medicaid providers for these specialty services was felt by many leaders as the reason for this. Other services that were difficult to find in the service area were cancer treatments, dental services, including orthodontics and oral surgery, cardiac surgery for infants, genetic testing, pediatric neurosurgery, cardiovascular surgery, immunology, psychiatry, and Medicaid nursing home beds. 85

87 It is generally believed that the residents of low-income and outlying areas, as well as those in Lehigh Acres, Dunbar, and LaBelle often have greater difficulty accessing health services. Also mentioned were East Fort Myers, Cape Coral, east side of Port Charlotte, Englewood, Hendry County, North Fort Myers, Punta Gorda, Alva, between Punta Gorda and Fort Myers, Bonita (migrant camps), Captiva Island, Clewiston, east Punta Gorda, Estero, Harbor Heights, Lake Suzy, Moorehaven, Parkside, Port Charlotte, and Tice. Transportation is seen as a barrier to care for many of these areas. Seven community leaders suggested that transportation in the service area needs improvement. Comments included, need upgraded routes and frequency of service, Our county transit system runs far enough and frequently enough, but it needs more health facility designated stops, Charlotte County service is curb to curb. We need a hybrid public transportation system- fixed route service from Punta Gorda to Englewood along 41. But keep the paratransit system, as this is helping a lot of elderly, and (in Lee County) Why don t we have vans like Charlotte County? Some seniors can barely get out of the house, let alone to a bus stop. Need picked up at curb if possible. Five interviewees felt the current transportation system needs subsidized, particularly for homeless and low-income residents to get to medical appointments. Three leaders noted that taking public transportation is extremely time consuming, adding to the challenges that some residents face in accessing needed healthcare. One interviewee stated, Buses are limited. Must take two or three, and similarly, another interviewee noted that the, bus lines don t cover a lot of area. There is a gap between Collier and Lee. They don t run very often it can take all day with transfers. One community leader suggested that doctors who are willing to go to their patients homes will have far fewer noshows than those who require patients to travel to their office for services. Affordable Care Act/Healthcare Reform Interviewees were asked their thoughts on how the Affordable Care Act will affect healthcare in the service area, and how best to educate the public about the upcoming changes. Eleven community leaders expressed positive feelings regarding the Affordable Care Act. Some suggested that more area residents will have health insurance, which could lead to more residents taking advantage of preventive care and using the emergency rooms less. Specific comments included, hopefully will drive access and quality, It will improve access to primary care for the uninsured, Pre-existing conditions will no longer limit people, and It s already increasing collaborative efforts; increasing focus on readmission of patients. Six community leaders had negative feelings about the changes stemming from the Affordable Care Act. One leader stated, I think it s horrible. I think a lot of people think they are getting free healthcare. Can t afford premiums. Resentful of having to pay for services they haven t been accessing. Another leader stated, I think it s going to be horrible. Nobody is going to be able to afford it. Other programs will likely be taken away, and the healthcare industry is going to get worse. Five leaders would not speculate on the effects of the Affordable Care Act. Three people suggested that the general population doesn t understand it. One leader stated, People who most need it don t understand it. Four leaders felt that the cost will be prohibitive to any potential positive benefit. 86

88 Educating the population of the service area about the upcoming changes may require multiple avenues. Suggestions primarily included using the media (television and radio) as well as the Internet and social media. It was suggested by multiple community leaders that information be made available on a one-on-one basis. Other suggestions included having information available at area clinics, churches, social service agencies, health fair, and on billboards and bus stop benches. Most Important Health Issue and How to Address It The number one health issue identified by most of the interviewed community leaders in the service area is education. Comments included, Teenagers get them to think about living a healthy life. Motivate them to be the leaders of tomorrow, starting from childhood education on healthy living, and increase health awareness. Several interviewees also felt that prevention is also a top concern for area residents. One leader stated that we need to try to keep people from lurching from crisis to crisis. It s very expensive and there are long-term consequences. Other issues mentioned were access to care, particularly primary care and particularly for the uninsured, affordability, a need for more mental health services, and having more specialty services available locally. A variety of ideas on how to implement change regarding these health issues in the service area were mentioned. The largest number of responses focused on education. One leader stated, It is everybody s responsibility. We need to educate people and advertise. The more people practicing healthy habits, the more affordable healthcare will become. Another stated, More info to public about access. It was suggested by some community leaders that the healthcare providers in the area should shoulder some of the responsibility. It was suggested by one community leader that area healthcare practitioners, do more pro bono work. Make medical licenses contingent upon a certain number of volunteer hours. Another stated, Providers should work together. Get rid of the competitive attitude. Six community leaders felt the government should take some of the responsibility for fixing current healthcare issues. One leader stated, County could do a lot more instead of worrying about stadiums care for citizens. Can t rely on hospitals and FQHC alone. Another stated, I think our county leadership needs to take responsibility in it. Keep seeking better solutions. Quality improvement isn t contingent on funding. Other suggestions included the following, Take care of things up front, less costly that way. Be your own advocate, do your own reading, Community task force of providers and consumers. Accountability should relate to payment must meet needs of community or you don t get paid, and Southwest Florida Planning Council and the Health Planning Council of Southwest Florida can work to determine the need, then community players can take action on it. 87

89 Additional comments from community leaders on health and health care in the service area included: Abuse - domestic violence, alcoholism, drug abuse. Women are often treated less in certain cultures. If services are available, we don't know about them / are they available in our language? We need more Doc-in-a-Boxes. [A popular term for a neighborhood or other retail-type medical office specializing in walk-in patients.] Need better system for processing a rape victim. Should go to rape center first, then ER afterwards for treatment. Transportation is one of the major issues for follow-up care, outpatient follow-up. If you have medical problems you can't walk 6 blocks to the bus. Lee Tran is not for those short term patients. We need to make an executive board - a group of providers, hospitals, FQHCs, etc. to assess the gaps and find a way to fill the gaps. It has to be holistic - recognizing the whole person. Our healthcare services need to focus. Doctors need to explain specifically how to care for your body. Healthcare providers need to focus on their job and not so much the extra stuff. I would like to see more health awareness. Lee Memorial used to have a huge Halloween health fair. Health fairs are great - kids activities. Should do more. Why is the county not helping? Why only one hospital system? Competition brings better service. Why is there not more being done for mental health? Issues are not just health; socio-economic issue. County - education, transportation, attract businesses like Hertz. Need industry. We have a high population of Medicaid and uninsured. Challenge to provide services and stay in business. It is tough to meet all the needs with the low rates of reimbursement. 88

90 Appendix A Lee County Data Demographic and Socioeconomic Characteristics This section provides a brief overview of some of the characteristics and trends that make Lee County unique in comparison to the state of Florida. Population Demographics Lee County, which has a population of approximately 635,500, is located in southwest Florida (Figure L- 1). The county also shares borders with the following counties: Charlotte to the north; Glades to the northeast; Hendry to the east; and Collier to the southwest. As seen in Figure L-2, Lee 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). Fort Myers is the county seat and Cape Coral is the largest city. Lee County is 1, square miles in area; 34 percent of that area is covered by water. The county has a population density of about 808 persons per square mile compared to a state average of 357 persons per square mile. Figure L-1: Figure L-2: 89

91 Population Growth The illustration below represents the total population of Lee County from The estimate for 2012 places the population of Lee County at 635,496. This represents a 52 percent increase since , , , , , , ,000 26, , , , , ,837 Chart L-1: Total Population Lee County , , , , , , , , , , 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 Lee County is expected to continue to grow in the coming years. In 2016, it is estimated that the population of Lee County will be 697,642; that is an increase of ten percent from the same number for , , , , , , , , , , , ,000 Chart L-2: Estimated Population Lee County , , , , , Source: The Florida Legislature, Office of Economic and Demographic Research 90

92 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, Lee County has a larger elder population, aged 65 and older, than the state as a whole (23.7% Lee vs. 18.0% State). The median age in Lee County is higher than the state (45.6 Lee vs State). Chart L-3: Population Percentage by Age Group Lee and State, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research Gender There are more women than men in Lee County. 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. 51 percent of the residents of Lee County are female while 49 percent are male; statewide the percentages are 51.1 percent female and 48.9 percent male Chart L-4: Lee Population by Sex Percent of Total Population, Lee State Male Female Source: The Florida Legislature, Office of Economic and Demographic Research 91

93 Race and Ethnicity 12.5 percent of the population of Lee County is non-white; compared to a statewide population comprised of 21.6 percent non-whites. Approximately 3.6 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 L-5: Lee Population by Race Percent of Total Population, 2012 Other, 3.6% Black, 8.9% White, 87.5% Source: The Florida Legislature, Office of Economic and Demographic Research Nearly twenty percent of the residents of Lee County identify as Hispanic; this is lower than the state average. The vast majority of the people in Lee County who identify as Hispanic identify as white. Table L-1: Race and Ethnicity, 2012 Lee State Hispanic Non-Hispanic Hispanic Non-Hispanic White 17.5% 70.0% White 21.2% 57.1% Black 0.9% 68.0% Black 1.2% 15.4% Other 0.8% 2.8% Other 0.8% 4.3% Total 19.2% 80.8% Total 23.2% 76.8% Source: The Florida Legislature, Office of Economic and Demographic Research 92

94 Socioeconomic Indicators Like the rest of Florida, Lee County was affected by the economic downturn. The unemployment rate jumped from 3.2 percent in 2000 to 8.9 percent in 2012; it is slightly higher than the state rate of 8.6 percent. The percent of people living under the poverty level in Lee County 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 slightly higher in Lee County; that rate is 25.9 percent for Lee County compared to 25.1 percent for the state. Table L-2: Socioeconomic Indicators Lee County and State County 2000 County 2012 State 2012 Labor Force as a % of Pop. Aged % 56.1% 62.5% Personal Bankruptcy Filing Rate per 1, Unemployment Rate 3.2% 8.9% 8.6% Average Annual Wage $36,478 $42,446 Per Capita Personal Income $29,451 $43,022* $39,636* % Living Below Poverty Level 15.3%* 17.0%* % ages 0-17 living below Poverty 25.9%* 25.1%* Source: The Florida Legislature, Office of Economic and Demographic Research *2011 data Slightly more residents of Lee County who are aged 25 and older have received a high school diploma than the state average. A slightly lower percentage of people in Lee County have received a Bachelor s degree than the percentage of residents of Florida who have done the same. Table L-3: Educational Attainment Persons aged 25 and older, Lee and State County State % High School graduate or higher 87.0% 85.5% % Bachelor's degree or higher 24.6% 26.0% Source: The Florida Legislature, Office of Economic and Demographic Research 93

95 As seen in Chart L-6, among working adults in Lee County the most common sectors of employment are: education and health services, retail trade, leisure and hospitality, and professional and business services. Chart L-6: Average Employment by Category Lee and State, 2012 Education & health services Retail trade Leisure & hospitality Professional and business services Construction Financial activities Other services Transportation, warehousing, & utilities Public administration Manufacturing Wholesale trade Information Agriculture, forestry, fishing & mining 8.5% 6.2% 7.2% 7.7% 4.7% 5.3% 3.7% 4.9% 3.6% 4.9% 3.3% 5.3% 2.2% 2.9% 1.7% 1.9% 0.9% 1.1% 16.2% 13.8% 14.3% 12.0% 12.4% 12.6% 21.3% 21.5% Lee State Source: Florida Legislature, Office of Economic and Demographic Research 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 94

96 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 Lee County currently ranked the 11 th healthiest out of 67 counties in Florida for Health Outcomes, and 24 th healthiest for Health Factors. Lee County was ranked the 10 th 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, Lee County ranked 18 th healthiest of all of the Florida counties. Lee County was ranked as the 22 nd 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 Lee County (47 per 1,000 female population, ages 15-19) was higher than that of the state (40) and considerably higher than the national benchmark (21). The rates of excessive drinking in Lee County (18%) were also higher than that of the state (16%) and were considerably higher than the national benchmark (7%). For clinical care, Lee County was ranked as the 28 th healthiest county. Clinical care includes data on the number of uninsured, primary care physicians, dentists, preventable hospital stays, diabetic screening, and mammography screening. In Lee County, the hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees (62) was slightly lower than that of the state average (65) but considerably higher than the national benchmark (47). The percent of female Medicare enrollees that receive mammography screening in Lee County (75%) was higher than that of the state average (70%) and the national benchmark (73%). Social & economic factors, where Lee County ranked 32 nd 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 Lee County, the percent of the children under age 18 living in poverty was 26 percent. This rate is slightly higher than that of the state (25%), and considerably higher than the national benchmark (14%). The percent of Lee County children living in single-parent households was 35 percent, which is slightly lower than the state average (37%) but significantly higher than the national benchmark (20%). 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, Lee County ranked 10 th healthiest. Lee County had lower than average rates of daily fine particulate matter (6.8 micrograms per cubic meter) than the state average (8.4) and the national benchmark (8.8). The percent of the Lee County population who are low-income and do not live close to a grocery store (limited access to healthy foods) (9%) was slightly higher than the state average (7%) and significantly higher than the national benchmark (1%). 95

97 County Health Rankings Definitions for each measure are listed on the next pages. Lee County Error Margin Florida National Benchmark* Health Outcomes 11 Mortality 10 Premature death 6,665 6,414-6,915 7,310 5,317 Morbidity 18 Poor or fair health 15% 13-17% 16% 10% Poor physical health days Poor mental health days Low birth weight 8.2% % 8.7% 6.0% Health Factors 24 Health Behaviors 22 Adult smoking 21% 18-24% 19% 13% Adult obesity 26% 23-29% 26% 25% Physical inactivity 23% 21-26% 24% 21% Excessive drinking 18% 16-21% 16% 7% Motor vehicle crash death rate Sexually transmitted infections Teen birth rate Clinical Care 28 Uninsured 27% 26-29% 25% 11% Primary care physicians** 1,616:1 1,439:1 1,067:1 Dentists** 2,447:1 2,095:1 1,516:1 Preventable hospital stays Diabetic screening 86% 84-87% 84% 90% Mammography screening 75% 73-77% 70% 73% Social & Economic Factors 32 High school graduation** 69% 71% Some college 52% 50-54% 59% 70% Unemployment 11.1% 10.5% 5.0% Children in poverty 26% 22-30% 25% 14% Inadequate social support 20% 18-23% 22% 14% Children in single-parent households 35% 32-37% 37% 20% Violent crime rate Rank (of 67) 96

98 Physical Environment 10 Daily fine particulate matter Drinking water safety 2% 3% 0% Access to recreational facilities Limited access to healthy foods** 9% 7% 1% Fast food restaurants 37% 44% 27% Source: County Health Rankings & Roadmaps. Available at Accessed October 2, *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 97

99 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 98

100 Healthy People 2020 Objectives Below is Lee County s Healthy People 2020 data with relation to selected objectives (comparing 2007 Behavioral Risk Factor Surveillance Survey data with 2010 data, available on page 151). Table L-4: Healthy People 2020 Objectives Lee County 2010 Objective Measure Progress AOCBC-2. Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms. 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. 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. IID Increase the percentage of noninstitutionalized adults aged 65 years and older who are vaccinated against seasonal influenza. Percentage of adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 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. 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 age 65 and over who received a flu shot in the past year. 14.9% 16.3% 65.1% 52.6% 55.1% 55.2% 66.7% 62.9% 65.3% 61.3% 75.3% 67.7% 78.0% 57.3% 69.0% 79.6% 67.8% 61.0% 62.7% 39.0% 32.6% 31.6% 37.9% 43.3% Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Needs Improvement Progress Shown Needs Improvement Needs Improvement Progress Shown Progress Shown 99

101 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 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). 68.5% 76.2% 35.2% 36.5% Percentage of adults who are obese. 23.9% 27.3% 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. 18.9% 18.1% 50.8% 64.2% Source: U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People Washington, DC. Available at Accessed September 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]. Progress Shown Progress Shown Needs Improvement Progress Shown Progress Shown 100

102 Death Rate The death rate for Lee County residents has been consistently lower than the state average. For the three-year period from , Lee County s death rate was eleven percent lower than the state s rate (603.4 per 100,000 Lee County vs State). The death rate for Lee County has been on the decline for the past twenty years, but has seen a slight increase since Chart L-7: Lee Death Rate over 20 Years Compared to State Age-Adjusted All Causes 3-Year Death Rate State Lee 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 Lee County is higher than that of whites (600.2 white population vs black population); this is also true for the state of Florida as a whole. From , the black population in Lee County had higher rates of death due to cancer, heart disease, stroke, diabetes and motor vehicle crashes than the white population. The black population in Lee County had diabetes death rates nearly three times as high as the white population (11.5 white population vs black population). The white population had considerably higher rates of death due to suicide than the black population (17.5 white population vs. 4.6 black population). The white population had nearly three times the rates for cirrhosis (12.3 white population vs. 4.2 black population). Cancer and heart disease were the leading causes of death for both whites and blacks. 101

103 Table L-5: Major Causes of Death and Race, Lee County 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 Suicide Diabetes Motor Vehicle Crashes Cirrhosis Alzheimer s Disease 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 L-8: Major Causes of Death and Race, Lee County 3-Year Age-Adjusted Death Rates by Cause White Black All Races Source: Florida Department of Health, Office of Vital Statistics 102

104 Leading Causes of Death Mortality rates can be key indicators of the state of health of a community. A significant number of Lee County 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 L-6 gives detailed information on the leading causes of death for residents of Lee County 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 Lee County, 36 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. 103

105 Table L-6: Major Causes of Death For 2012 Lee County Cause of Death 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 5, % ,445 CANCER 1, % ,199 HEART DISEASE 1, % ,955 CHRONIC LOWER RESPIRATORY DISEASE % ,126 UNINTENTIONAL INJURY % ,679 STROKE % ,190 DIABETES % ALZHEIMER'S DISEASE % SUICIDE % ,430 CIRRHOSIS % ,273 KIDNEY DISEASE % 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 104

106 The most frequent causes of death for people in Lee County are cancer and heart disease. Together they accounted for 49.8 percent of the deaths in Table L-7, which compares the three-year ageadjusted rates for Lee County with those for all of Florida, shows that the death rates in Lee County for cancer, heart disease, and stroke are significantly lower than the state average. The death rate for Lee County is slightly higher than the state average for unintentional injuries and suicide. Table L-7: Major Causes of Death Lee and State County Florida Age-Adjusted Rate/100,000 Age-Adjusted Rate/100,000 Cause of Death All Causes Cancer Heart Disease Chronic Lower Respiratory Disease Unintentional Injury Stroke Diabetes Alzheimer s Disease Suicide Chronic Liver Disease & Cirrhosis Source: Florida Department of Health, Office of Health Statistics and Assessment Age-adjusted death rates are computed using the year 2000 standard population. 105

107 Chronic Diseases Cancer Cancer is the leading cause of death in Lee County. Chart L-9 gives a detailed look at the decline in deaths from all cancers across the last twenty years. The decline in Lee County is not as smooth as the decline at the state level, although it has been consistently lower in Lee than for the state as a whole. Despite a few higher years, the overall trend is mostly positive. In fact, Lee County had the sixth lowest three-year rate of deaths from all cancers of all 67 counties in Florida for Chart L-9: Deaths from All Cancers Age-adjusted rate per 100,000, 3-Year Rates State Lee Source: Florida Department of Health, Bureau of Vital Statistics 106

108 Cancer incidence in Lee County is fairly consistent with the state as a whole. After a brief climb in the early 1990s, Lee County is now seeing a slight downward trend. 600 Chart L-10: Cancer Incidence Age-adjusted rate per 100,000, 3-Year Rates State Lee Source: Florida Department of Health, Bureau of Vital Statistics Among the types of cancer, lung cancer causes the highest number of deaths in Lee County. The incidence of prostate cancer is significantly higher than the incidence of lung cancer in Lee County, but it is not nearly as deadly. Table L-8: Common Types of Cancer Death Rate and Incidence, Lee County 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. 107

109 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 on page 151), women over 18 years of age in Lee County 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 (52.6% Lee vs. 57.1% State). The rate is lowest for those women who with incomes between $25,000 and $49,999 annually. Chart L-11: Women 18 Years of Age or Older Who Received a Pap Test in the Past Year Percentage By Income, Lee County % 74.5% 70.0% 60.0% 50.0% 49.4% 43.7% 40.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. Women ages 40 years and older are recommended to receive a mammogram, an x-ray of the breast, annually to detect and/or diagnose breast cancer. A slightly higher percentage of women 40 years or older in Lee County reported that they had received a mammogram than the state average (62.9% Lee vs. 61.9% State). Income played a significant factor; women with incomes below $25,000 annually had the lowest rates. Chart L-12: Women 40 Years of Age and Older Who Received a Mammogram in the Past Year Percentage By Income, Lee County % 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 48.3% 68.0% 72.6% <$25,000 $25,000-$49,999 $50,000 or More 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]. 108

110 Residents of Lee County over the age of 50 indicated that they are slightly less likely to have received a sigmoidoscopy or colonoscopy, screening exams for colorectal cancer, in the past five years than the state average for 2010 (55.2% Lee vs. 56.4% State). Women were more likely than men to have received a sigmoidoscopy or colonoscopy (56.5% women vs. 53.8% men) and those who are married were more likely to have been screened than their non-married counterparts (61.7% married/couple vs. 43.6% not married/couple). As with other screenings, those with lower annual incomes were the least likely to have received a sigmoidoscopy or colonoscopy in the past five years. Chart L-13: Percentage of Adults 50 Years of Age and Older Who Received a Sigmoidoscopy or Colonoscopy in the Past Five Years Percentage By Income, Lee County % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 40.4% 59.2% 55.4% 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]. There has been a decrease in the number of adults 50 years or older who indicated that they have received a blood stool test (14.5% 2010 vs. 21.5% 2007); these rates are similar the average across the state (14.5% Lee 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 Lee County (8.4%) compared to those with incomes $25,000 to $49,999 (14.2%) or $50,000 and more (15.3%). Chart L-14: Percentage of Adults 50 Years of Age and Older Who Received a Blood Stool Test in the Past Year Percentage By Income, Lee County % 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 8.4% 14.2% 15.3% <$25,000 $25,000-$49,999 $50,000 or More 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]. 109

111 Heart Disease Heart disease is the second most common cause of death in Lee County. As seen in Chart L-15, ageadjusted death rates from heart disease have been on the decline for both Lee County and the state of Florida as a whole during this time period. 300 Chart L-15: Deaths from Heart Disease Age-adjusted rate per 100,000, 3-Year Rates State Lee Source: Florida Department of Health, Bureau of Vital Statistics 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 Lee County, the percentage of adults who reported that they had ever had a heart attack, angina, or coronary heart disease was slightly higher than for the state as a whole in 2010 (11.7% Lee vs. 10.2% State). Residents with lower annual incomes reported the highest rates. Chart L-16: Adults Who Ever Had a Heart Attack, Angina, or Coronary Heart Disease Percentage by Income, Lee County % 20.0% 19.3% 15.0% 10.0% 5.0% 11.5% 7.8% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 110

112 Diabetes Deaths rates for diabetes in Lee County are much lower than those for cancer and heart disease, but are still a health concern. The age-adjusted three-year rates have fluctuated over the last twenty years, from a high of 19.7 per 100,000 ( ) to its current low of 12.3 per 100,000 ( ), and have remained consistently lower than the state average. In fact, for the three year period of , Lee County ranked 5 th lowest of the 67 counties in Florida with a rate of 12.3 per 100, Chart L-17: Deaths from Diabetes Age-adjusted rate per 100,000, 3-Year Rates State Lee Source: Florida Department of Health, Bureau of Vital Statistics 111

113 Lee County has a slightly lower rate of adults diagnosed with diabetes than the state (9.0% Lee vs. 10.4% State). The number of men reporting a diabetes diagnosis has decreased since 2007 (10.5% 2010 vs. 11.5% 2007), and the number of women reporting this chronic condition has decreased as well (7.6% 2010 vs. 9.4% 2007). 14.0% Chart L-18: Adults with Diagnosed Diabetes Percentage by Sex, 2007 and % 10.0% 11.5% 10.5% 11.7% 9.4% 9.2% 10.4% 10.4% 9.0% 8.0% 6.0% 4.0% 7.6% 2007 Lee 2010 Lee 2010 Florida 2.0% 0.0% Men Women Overall 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]. 112

114 Residents with lower annual incomes reported much higher rates of diabetes than those with the highest incomes. Residents with annual incomes between $25,000 and $49,999 reported a 11.4% rate in 2010, while those with incomes $50,000 or more only reported a 5.7% rate of diagnosed diabetes. Chart L-19: Percentage of Adults with Diagnosed Diabetes Percentage By Income, Lee County % 11.4% 10.0% 9.7% 8.0% 6.0% 5.7% 4.0% 2.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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, fewer Lee County residents reported ever having participated in diabetes self-management education than the state as a whole (39.0% Lee vs. 55.1% State). 113

115 Communicable Diseases Lee County 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 L-10: Communicable Diseases Lee County 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 2, 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 114

116 Sexually Transmitted Diseases Chlamydia is the most prevalent sexually transmitted disease in Lee County with an average of 2,036.7 cases per year between 2010 and That works out to a rate per 100,000 of 324.5; 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 Lee County have also seen a slight increase, but have remained below the state rate over the past decade Chart L-20: Chlamydia Cases 3-Year Rate per 100, State Lee Source: Florida Department of Health, Bureau of STD Prevention & Control 115

117 Vaccine Preventable Diseases The overall rate of infection from vaccine preventable diseases is very low in Lee County. 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 Lee County with an average of 17.3 cases per year between 2010 and At a 3-year rate of 3.5 per 100,000, Lee County is seeing its highest rates in twenty years, fortunately there has not been a death attributed to pertussis in Lee County in at least forty years. 4 Chart L-21: Pertussis Cases 3-Year Rate per 100, State Lee Source: Florida Department of Health, Bureau of Epidemiology 116

118 Hepatitis B, a contagious liver disease that results from infection with the Hepatitis B virus, is, is another vaccine preventable disease being seen more frequently in recent years in Lee County in recent years with an average of 10.3 cases per year between 2010 and At a 3-year rate of 1.7 per 100,000, Lee County is seeing its highest rates in the last five years, and rates higher than the state average for the first time since Chart L-22: Acute Hepatitis B Cases 3-Year Rate per 100, Florida Lee Source: Florida Department of Health, Bureau of Epidemiology 117

119 AIDS and Other Diseases An average of 59.0 people per year was diagnosed with AIDS in Lee County between 2010 and The rate per 100,000 in Lee County is 9.4 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 Lee County residents has decreased 30 percent over the past decade (13.4 per 100,000 in vs. 9.4 per 100,000 in ) Chart L-23: AIDS Cases 3-Year Rate per 100, State Lee Source: Florida Department of Health, Bureau of HIV/AIDS The rate of tuberculosis, an infectious bacterial disease, in Lee County is slightly higher than the state as a whole at 3.0 per 100,000 compared to 2.9 per 100,000. While these numbers are higher than the state average, they are on a downward trend. Lee County had a 3-year high of 9.4 per 100,000 in , and has seen a 68 percent decrease since then. 12 Chart L-24: Tuberculosis Cases 3-Year Rate per 100, State Lee 2 0 Source: Florida Department of Health, Bureau of TB and Refugee Health 118

120 Maternal and Child Health On average, 6,329.0 babies were born per year in Lee County between 2010 and 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 Lee County for births to teenage mothers are nearly identical to the state, and have been declining in recent years. Infant mortality rates are considered a primary indicator of the health of a community. Infant mortality rates for this time period in Lee County are slightly lower than the average for the state of Florida, and continue to decline. Table L-11: Maternal & Child Health Indicators, Lee County & State 3-Year Figures, Births County State Trend Quartile* Total Births (3-yr annual avg.) 6,329.0 Births to Mothers ages 15-44, per 1, Births to Mothers ages 10-14, per 1, Positive 3 Births to Mothers ages 15-19, per 1, Positive 2 Percent of Births to Unwed Mothers Negative 2 Infant Deaths Infant Deaths (0-364 days) per 1,000 Births Positive 2 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 Negative 3 Percent of Births < 2500 Grams Steady 2 Prenatal Care Percent of Births with 1st Trimester Prenatal Care Steady 2 Percent of Births with Late or No Prenatal Care Positive 2 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. 119

121 Teen Births In the 3-year period from 2010 through 2012, Lee County saw its lowest rates of live births to teenage and pre-teen mothers (16.3 births per 1,000). Lee County s rates of teen births have been consistently higher than the rates for the state of Florida. Rates for both the state and Lee County have been declining. 40 Chart L-25: Births to Mothers ages Year Rate per 1, State Lee Source: Florida Department of Health, Bureau of Vital Statistics 120

122 Infant Deaths Infant deaths in Lee County have declined fairly consistently since the most recent peak in (9.1 per 1,000 births). There were 108 infant deaths in (5.7 per 1,000 births) Chart L-26: Infant Deaths (0-364 days) 3-Year Rate per 1, State Lee Source: Florida Department of Health, Bureau of Vital Statistics 121

123 Mothers Who Smoked During Pregnancy Lee County s rates have been consistently higher than that of the state. For the 3-year period from 2010 through 2012, Lee County had a rate of 9.5 births per 1,000 to mothers who smoked during pregnancy, as compared to the state average of 6.8 births per 1,000. This rate has seen a 56 percent decrease over the past twenty years, from a high of 21.4 births per 1,000 to mothers who smoked during pregnancy for to its current rate of 9.5 births per 1,000 for Chart L-27: Births to Mothers who Smoked During Pregnancy 3-Year Rate per 1, State Lee Source: Florida Department of Health, Bureau of Vital Statistics 122

124 Oral Health According to the Behavioral Risk Factor Surveillance System 2010 Data Report (available on page 151), a slightly larger percentage of adults in Lee County reported that they had visited a dentist or dental clinic in the past year than the same for the state (66.5% Lee vs. 64.7% State). Men were more likely than women to have reported a visit to a dentist of dental clinic (69.2% men vs. 64.0% 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 while only 48.8 percent of those with incomes under $25,000 annually only reported the same. Chart L-28: Adults Who Visited a Dentist or Dental Clinic in the Past Year Percentage By Income, Lee County % 83.1% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 48.8% 61.3% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 123

125 Lee County residents reported slightly higher rates of having a permanent tooth removed because of tooth decay or gum disease than adults across the state (53.6% Lee vs. 53.0% State). Income levels, again, played a role in the percentage of these procedures amongst Lee County residents. Chart L-29: Adults Who Had a Permanent Tooth Removed Because of Tooth Decay or Gum Disease Percentage By Income, Lee County % 70.0% 68.4% 60.0% 50.0% 40.0% 45.4% 46.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 124

126 The percentage of Lee County adults who reported that they had their teeth cleaned in the past year mirrors the state rate (60.9%). Men were more likely than women to have had their teeth cleaned (63.5% men vs. 58.4% women) and those who were married reported higher rates than those who were not married (65.3% married/couple vs. 51.5% not married/couple). Those with higher annual income levels were significantly more likely to have had a cleaning than those with lower annual incomes. 90.0% 80.0% 70.0% 60.0% Chart L-30: Adults Who Had Their Teeth Cleaned in the Past Year Percentage By Income, Lee County % 61.9% 50.0% 40.0% 30.0% 32.3% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 125

127 Accessibility for Low-Income Residents According to data from the Florida Department of Health Public Health Dental Program, Lee County 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 (32.7% in ), they are on par with the state of Florida as a whole, and the most recent year s data is 36 percent higher than in Chart L-31: Percentage of Low-Income Persons* with Access to Dental Care 3-Year Rate State Lee Source: Florida Department of Health, Public Health Dental Program *Low-Income Persons are defined as those living below the poverty level. 126

128 Dental Emergencies A lack of access to dental care can lead to avoidable visits to the local emergency room and avoidable hospitalizations. In 2012, Lee County hospitals received 3,143 emergency room visits for dental conditions that are typically considered avoidable with appropriate preventive care. The charges for these avoidable visits totaled $2,048,183. Table L-12: Avoidable Emergency Department Visits for Dental Conditions as Patient s Reason for Visit Lee County Hospitals, April 2012 through March 2013 Total Emergency Average Total Facility Department Visits* Charges Charges CAPE CORAL HOSPITAL 802 $548 $439,788 GULF COAST MEDICAL CENTER 470 $595 $279,621 HEALTHPARK MEDICAL CENTER 369 $742 $273,766 LEE MEMORIAL HOSPITAL 1,107 $543 $601,563 LEHIGH REGIONAL MEDICAL CENTER 395 $1,148 $453,445 TOTAL 3,143 $652 $2,048,183 Source: Florida Health Finder Emergency Department Query. Available at Accessed October 8, *The data shown does not include emergency department visits that resulted in an admission to the hospital. Preventable hospitalizations for Lee County residents under 65 years of age have steadily risen over the last several years. The rate per 100,000 had remained below the Florida rate until 2009, when Lee County s rate surpassed it. Chart L-32: Preventable Hospitalizations Under 65 from Dental Conditions 3-Year Rate per 100, State Lee Source: Florida Agency for Health Care Administration (AHCA) 127

129 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 most categories Lee County ranks in the second and third quartiles (average) for crime in the state of Florida. Lee County ranks below the state rate for all categories of crime and domestic violence except for murder. Table L-13: Lee County Crime and Domestic Violence 3-Year Rate per 100,000, County State Quartile* Larceny 1, , Burglary Total Domestic Violence Offenses 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 Lee County. These rates, although high, have seen a steady decline from a high in of 3,124.0 per 100,000 population to a current low of 1,749.9 per 100, Chart L-33: Larceny in Lee County 3-Year Rate Per 100,000 Population State Lee Source: Florida Department of Law Enforcement 128

130 Burglary, also called breaking and entering, had the second highest rates of all of the crime and domestic violence indicators in Lee County. These rates have seen a steady decline in Lee County over the last twenty years Chart L-34: Burglary in Lee County 3-Year Rate Per 100,000 Population State Lee Source: Florida Department of Law Enforcement 129

131 Alcohol-related Motor Vehicle Crashes In 2011 Lee County residents were involved in 4,418 motor vehicle traffic crashes, according to the Florida Department of Highway Safety and Motor Vehicles. Of these, 12.9 percent (570 crashes) were alcohol-related. In that same year there were 82 motor vehicle traffic crash deaths; 30 percent (25 deaths) were alcohol-related Chart L-35: Motor Vehicle Crash Deaths in Lee County Total Deaths and Alcohol-related Deaths, Motor Vehicle Crash Deaths Alcohol-related Motor Vehicle Traffic Crash 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, Lee County had lower rates for all of the alcohol-related motor vehicle crash indicators for the three year period from 2009 to Lee County ranked in the 1 st Quartile for alcohol-related motor vehicle crash deaths. Table L-14: Lee County 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. 130

132 The percent of adults who reported on the Behavioral Risk Factor Surveillance System survey that they engage in heavy or binge drinking in Lee County decreased from 18.9 percent in 2007 to 18.1 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 Lee County (22.3 men vs women). The highest rate is among people between 18 and 44 (24.2) and lowest among people over the age of 65 (9.1). Persons with higher income levels reported drinking at slightly higher rates than those with lower annual incomes. Chart L-36: Percentage of Adults who Engage in Heavy or Binge Drinking Percentage By Income, Lee County % 21.9% 20.0% 17.4% 17.6% 15.0% 10.0% 5.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 131

133 Florida Youth Substance Abuse Survey 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 Lee County, 1,994 students completed the survey (1,219 middle school students; 775 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 25.5 percent for Lee County students in 2012, which was slightly lower than the state average of 24.6 percent had the lowest percentage of Lee County students reporting that they had used alcohol in the past 30 days in the years surveyed, with a peak of 36.5 percent in % 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Chart L-37: Past-30-Day Alcohol Use Lee County and Florida Statewide 2012 Middle School High School Overall 2002 Lee 2004 Lee 2006 Lee 2008 Lee 2010 Lee 2012 Lee 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 132

134 The percentage of students reporting cigarette use over the past 30 days in Lee County in 2012 was slightly higher than the Florida average (7.6% Lee vs. 6.6% State). This is lower for Lee County than past years, with a high of 13.9 percent in Females are more likely to report cigarette use than males (6.9% males vs. 8.2% females). 20.0% Chart L-38: Past-30-Day Cigarette Use Lee County and Florida Statewide % 10.0% 5.0% 0.0% Middle School High School Overall 2002 Lee 2004 Lee 2006 Lee 2008 Lee 2010 Lee 2012 Lee 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Past-30-day marijuana use for Lee County students in 2012 was slightly higher than for students across the state as a whole (13.3% Lee vs. 12.4% State). The overall percentage of Lee County students who have reported marijuana use has seen a decrease since 2002, from a high of 15.1 percent in 2002 to a low of 11.5 percent in High school students surveyed were seven as likely to have used marijuana as middle school students (20.9% high school students vs. 3.0% middle school students). 25.0% Chart L-39: Past-30-Day Marijuana Use Lee County and Florida Statewide % 15.0% 10.0% 5.0% 0.0% Middle School High School Overall 2002 Lee 2004 Lee 2006 Lee 2008 Lee 2010 Lee 2012 Lee 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 133

135 The FYSAS asks youth if they have ever used various drugs. Table L-15 below illustrates the high incidence of youth having ever tried alcohol, cigarettes, and marijuana in particular. Also relatively high were the percentage of Lee County high school students in 2012 who reported having ever used synthetic marijuana (13.8%), and the percentage of middle school students who reported having ever used inhalants (8.7%). These rates are similar to Florida s statewide averages for the same substances. Table L-15: Percentages of Youth Who Reported Having Used Various Drugs in their Lifetimes 2012 Middle School Lee County 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 Past 30-day drug use is detailed in Table L-16 and Table L

136 Table L-16: Percentages of Youth Who Reported Having Used Various Drugs in the Past 30 Days 2012 Lee County Florida Statewide Middle High Ages Ages Middle High Ages Ages School School Female Male Overall School School Female Male Overall Alcohol Binge Drinking 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 Any illicit drug Any illicit drug other than marijuana Alcohol only Alcohol or any illicit drug Any illicit drug, but no alcohol Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Note: The first 16 rows show results for alcohol, cigarettes, and other drugs. The last five data rows show results for various combinations of drugs. Binge drinking is defined as having had five or more alcoholic drinks in a row in the past two weeks. Ecstasy, Rohypnol, GHB and ketamine are provided as examples in the question about club drugs. Table L-17: Past 30-day Trend in Alcohol, Tobacco and Other Drug Use for Lee County Youth 2002, 2004, 2006, 2008, 2010 and Middle High Middle High Middle High Middle High Middle High Middle High School School Overall School School Overall School School Overall School School Overall School School Overall School School Overall Alcohol Binge Drinking Cigarettes Marijuana or Hashish 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 Any illicit drug Any illicit drug other than marijuana Alcohol only Alcohol or any illicit drug Any illicit drug, but no alcohol Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Note: The first 15 rows show results for alcohol, cigarettes, and other drugs. The last five data rows show results for various combinations of drugs. Binge drinking is defined as having had five or more alcoholic drinks in a row in the past two weeks. Ecstasy, Rohypnol, GHB and ketamine are provided as examples in the question about club drugs. 135

137 Suicides The suicide rate for Lee County has fluctuated over the last twenty years, decreasing about eight percent since 1993 ( vs ). Lee County has consistently had higher rates of suicide than the state of Florida as whole Chart L-40: Age-Adjusted Suicide Death Rate 3-Year Rate Per 100,000 Population State Lee Source: Florida Department of Health, Bureau of Vital Statistics. 136

138 Baker Act There were 3,582 involuntary examinations in Lee County in This number has more than doubled since 2002 (1,699 involuntary examinations). The rate per 100,000 of the population in Lee County that was given an involuntary exam in 2012 was lower than the state rate (563.7 Lee vs State). Of those in Lee County, percent were initiated by law enforcement, percent were initiated by mental health professionals, and 1.45 percent were initiated by judges. 900 Chart L-41: Involuntary Examinations* Single Year Rate Per 100,000 Population State Lee 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. 137

139 Hospitalizations Prevention Quality Indicators Congestive heart failure, bacterial pneumonia, chronic obstructive pulmonary disease (this category includes chronic bronchitis and emphysema) and urinary infections are the most common preventable causes of hospitalizations for Lee County residents. Lee County s 2012 rates of hospitalizations due to chronic obstructive pulmonary disorder, urinary infections and angina without procedure were higher than the state of Florida as a whole. Since 2007, rates of dehydration have decreased by half ( vs ). Rates of angina without procedure have increased by 46 percent in that same time ( vs ). Table L-18: Prevention Quality Indicators Annual Rate per 100, , Lee County 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 Lee County residents in any hospital in Florida. 138

140 Chronic Conditions Hypertension is the number one cause of hospitalization for a chronic condition for Lee County residents and the rates are rising. Table L-19: Hospitalizations for Chronic Conditions Annual Figures, , Lee County Residents Disease Diabetes 13,606 14,377 16,117 17,021 16,592 Asthma Congestive Heart Failure Hypertension AIDS Sickle Cell 4,485 5,071 5,217 5,268 5,397 7,591 8,204 9,083 9,725 9,960 27,151 29,019 32,869 33,742 33, Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of Lee County residents in any hospital in Florida. 139

141 Emergency Room Visits Lee County residents made 148,419 visits to hospitals in 2012 that did not result in an inpatient admission. The largest number of visits was made to Healthpark Medical Center. The next largest numbers of visits were made to Lehigh Regional Medical Center, Cape Coral Hospital, Gulf Coast Medical Center, and Lee Memorial Hospital. Table L-20: Emergency Room Visits by Lee County Residents by Payer Source 2012 Medicaid Medicare No charge/ Charity Other Private, incl. HMO Self- Pay* Grand Total Healthpark Medical Center 16,193 5,123 2,352 1,240 8,342 3,560 36,810 Lehigh Regional Medical Center 13,234 2, ,690 4,644 25,157 Cape Coral Hospital 6,976 6,326 1,782 1,289 5,327 3,247 24,947 Gulf Coast Medical Center 7,113 5, ,375 5,431 4,571 24,105 Lee Memorial Hospital 5,959 4,154 2,203 1,204 3,567 5,283 22,370 NCH Healthcare System North Naples Hospital 2,111 1, ,453 1,308 7,630 Physicians Regional Medical Center - Pine Ridge ,504 Naples Community Hospital Charlotte Regional Medical Center Physicians Regional Medical Center - Collier Blvd Peace River Regional Medical Center Sarasota Memorial Hospital Fawcett Memorial Hospital Englewood Community Hospital Hendry Regional Medical Center Florida Hospital Celebration Health Shands Hospital at The Univ. Of Florida Dr P Phillips Hospital Venice Regional Medical Center University Community Hospital Total 53, % 27, % 7, % 6, % 29, % 24, % 148, % 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 Lee County 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 75 visits are included in the chart above. There are an additional 3,192 visits divided amongst 178 hospitals that have not been included in the chart, but are included in the total. 140

142 Health Resources 19.3 percent of adults in Lee County 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 worse than the state average of 17.3 percent. More Lee County women reported not being able to see a doctor in the past year due to cost than men in Chart L-42: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Sex, Lee County % 20.0% 15.0% 12.2% 17.8% 15.4% 20.7% 19.1% 19.0% 15.7% 19.3% 17.3% 2007 Lee 10.0% 2010 Lee 2010 Florida 5.0% 0.0% Men Women Overall 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]. 141

143 Annual income and age had the greatest effect in Lee County 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 4.9 percent, while those with annual incomes below $25,000 reported a rate of 46.3 percent. Chart L-43: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Income, Lee County % 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 46.3% 16.9% 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]. 4.9% <$25,000 $25,000-$49,999 $50,000 or More 142

144 Older Lee County residents had significantly less difficulty seeing a doctor than their younger counterparts. Chart L-44: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Age, Lee County % 35.0% 30.0% 25.0% 33.6% 20.0% 18.3% 15.0% 10.0% 5.0% 0.0% 3.4% & Older 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]. 143

145 71.0 percent of adults in Lee County 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 Lee County residents were to have had a medical checkup. Those with the highest annual incomes ($50,000 or more) had the highest rates (76.9%) of all income groups. 90.0% 80.0% 70.0% 60.0% Chart L-45: Percentage of Adults who had a Medical Checkup in the Past Year Percentage by Income, Lee County % 69.2% 76.9% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 144

146 Medicaid Eligibility for each of those programs is based on specific income criteria. As of 2011, approximately 14,900 out of every 100,000 people in Lee County 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 Chart L-46: Median Monthly Medicaid Enrollment Single-Year Rate Per 100,000 Population State Lee Source: Florida Department of Health, Office of Planning, Evaluation & Data Analysis 145

147 Florida 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 L-21: Monthly Children s Health Insurance Enrollment Lee County Florida Healthy Kids MediKids CMS Total Active Children September, ,781 1, ,775 October, ,721 1, ,664 November, ,741 1, ,714 December, ,696 1, ,701 January, ,569 1, ,524 February, ,776 1, ,766 March, ,907 1, ,905 April, ,984 1, ,021 May, ,177 1, ,229 June, ,254 1, ,318 July, ,181 1, ,196 August, ,216 1, ,240 Source: Florida Healthy Kids Corporation 11,400 11,200 11,000 10,800 10,600 10,400 10,200 10,000 Chart L-47: Total Monthly Children s Health Insurance Enrollment Lee County Source: Florida Healthy Kids Corporation 146

148 Uninsured As of 2011, Lee County was estimated as having 30.6 percent of adults without health insurance; this compares to a rate of 29.3 percent for Florida as a whole. This number is a 4.4 percent decrease from 2006, but is on the rise after a low of 27.8 percent in In 2011 Lee County had the 14 th highest percentage of uninsured adults out of the 67 counties in Florida. 33.0% Chart L-48: Uninsured Adults (Age 18 64) % 31.0% 30.0% 29.0% 28.0% 27.0% Lee State 26.0% 25.0% 24.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 147

149 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, 53.6 percent of Lee County adults with incomes at or below 138% of the Federal Poverty Level (FPL) were uninsured. Lee County adults with incomes above 400% of the FPL only had a rate of 10.9 percent being without health insurance. Chart L-49: Uninsured Adults (Age 18 64) Percentage by Income (based on Federal Poverty Level), Lee County Insured Uninsured % 34.5% 10.9% 30.6% <=138% of Poverty 139% - 400% of Poverty >400% of Poverty All Incomes Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 148

150 While the percentage of adults who are uninsured has increased since 2008, Lee County residents under the age of 19 have seen the opposite trend. Since 2006, the number of uninsured youth has decreased 45.8 percent to a low of 14.1 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 Lee County had the 15 th highest percentage of uninsured youth of the 67 Florida counties. 30.0% Chart L-50: Uninsured Youth (Under 19 Years) % 20.0% 15.0% 10.0% Lee State 5.0% 0.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) As with the adult population in Lee County, youth living in households with income levels near and below the Federal Poverty Level had the highest rates of being uninsured Chart L-51: Uninsured Youth (Under 19 Years) Percentage by Income (based on Federal Poverty Level) Lee County % 15.2% 4.8% 14.1% <=138% of Poverty 139% - 400% of Poverty >400% of Poverty All Incomes Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) Insured Uninsured 149

151 Physicians and Facilities As of 2011, there were one thousand, five hundred and twenty-one licensed physicians in Lee County. 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 lower rate per 100,000 than the state for licensed pediatricians (19.3 Lee vs State). The number of Lee County Health Department employees per every 100,000 residents is lower than the state average. The Lee County Health Department spent $15,273,551 dollars in 2011; that places the rate of expenditure per 100,000 residents at just over half the state average. Providers* Table L-22: Health Resources Availability Lee County & State 2011 County Rate per Number 100,000 Quartile** State Rate per 100,000 Total Licensed Dentists Total Licensed Physicians 1, Total Licensed Family Private Practice Physicians Total Licensed Internists Total Licensed OB/GYN Total Licensed Pediatricians Facilities Total Hospital Beds 1, Total Acute Care Beds 1, Total Specialty Beds Total Skilled Nursing Home Beds 2, County Health Department County Health Department Full-Time Employees County Health Department Expenditures $15,273,551 $2,434,210 1 $4,204,339 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. 150

152 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 Lee County 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. 18.1% 15.0% 18.9% 4 ( ) ( ) ( ) Arthritis Adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 16.3% ( ) 14.9% ( ) 14.9% ( ) Adults who have been told they have some form of arthritis. 32.4% 32.0% 28.3% ( ) ( ) ( ) Asthma Adults who currently have asthma. 11.4% 8.3% 3.5% 4 ( ) ( ) ( ) Cancer Screening Adults 50 years of age and older who received a blood stool test in the past year. 14.5% ( ) % ( ) 21.5% ( ) Adults 50 years of age and older who received a sigmoidoscopy or colonoscopy in the past five years. 55.2% ( ) % ( ) 55.1% ( ) Adults ages 50 years and older who have ever had a blood stool test. 45.1% ( ) % ( ) 47.2% ( ) Adults ages 50 years and older who have ever had a sigmoidoscopy or colonoscopy. 71.1% ( ) % ( ) 64.8% ( ) Men 45 years of age and older who have been told they have prostate cancer. 8.1% ( ) 3 7.3% ( ) Men ages 50 years and older who have ever had a digital rectal exam. 86.9% ( ) % ( ) 88.8% ( ) Men ages 50 years and older who have ever had a PSA test. 82.0% 85.0% 83.0% 3 ( ) ( ) ( ) 151

153 Women 18 years of age and older who received a Pap test in the past year. 52.6% ( ) % ( ) 65.1% ( ) Women 40 years of age and older who received a mammogram in the past year. 62.9% ( ) % ( ) 66.7% ( ) Women ages 40 years and older who had a clinical breast exam in the past year. 64.2% ( ) % ( ) 64.8% ( ) Women who have had a hysterectomy. 29.1% 26.2% 2 ( ) ( ) Cardiovascular Disease Adults who have ever had a heart attack, angina, or coronary heart disease. 11.7% ( ) % ( ) 11.0% ( ) Adults who have ever had a stroke. 3.9% 3.5% 3.5% 3 ( ) ( ) ( ) Cholesterol Awareness Adults who have diagnosed high blood cholesterol. 45.0% 38.6% 41.6% ( ) ( ) ( ) Dental Care Adults who had a permanent tooth removed because of tooth decay or gum disease. 53.6% ( ) % ( ) Adults who had their teeth cleaned in the past year. 60.9% 60.9% 2 ( ) ( ) Adults who visited a dentist of dental clinic in the past year. 66.5% 64.7% 1 ( ) ( ) Diabetes Adults with diabetes who ever had diabetes self-management education. 39.0% ( ) % ( ) 62.7% ( ) Adults with diabetes who had an annual eye exam. 57.3% 70.2% 78.0% 4 ( ) ( ) ( ) Adults with diabetes who had an annual foot exam. 67.7% 72.2% 75.3% 3 ( ) ( ) ( ) Adults with diabetes who had two A1C tests in the past year. 79.6% % 69.0% ( ) ( ) ( ) Adults with diagnosed diabetes. 9.0% 10.4% 10.4% 1 ( ) ( ) ( ) Disability Adults who are limited in any way in any activities because of physical, mental, or emotional problems. 26.5% ( ) % ( ) 15.5% ( ) 152

154 Adults who use special equipment because of a health problem. 11.0% ( ) 3 9.3% ( ) 6.5% ( ) 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. 60.6% ( ) 56.2% ( ) Health Care Access & Coverage Adults who could not see a doctor at least once in the past year due to cost. 19.3% ( ) % ( ) 15.7% ( ) Adults who had a medical checkup in the past year. 71.0% 69.7% 72.2% 1 ( ) ( ) ( ) Adults who have a personal doctor. 83.1% 81.7% 78.7% 2 ( ) ( ) ( ) Adults who think they would get better medical care if they belonged to a different race/ethnic group. 14.2% ( ) 10.8% ( ) Adults with any type of health care insurance coverage. 79.7% 83.0% 79.8% 3 ( ) ( ) ( ) Health Status & Quality of Life Adults who always or usually receive the social and emotional support they need. 77.2% ( ) % ( ) 77.8% ( ) Adults who had poor mental health on 14 or more of the past 30 days. 14.5% ( ) % ( ) 7.9% ( ) Adults who had poor physical health on 14 or more of the past 30 days. 14.6% ( ) % ( ) 10.3% ( ) Adults who said their overall health was "fair" or "poor". 16.5% 17.1% 14.8% 2 ( ) ( ) ( ) Adults whose poor physical or mental health kept them from doing usual activities on 14 or more of the past 30 days. 17.0% ( ) % ( ) 12.1% ( ) Adults with good mental health. 85.5% 88.2% 92.1% 3 ( ) ( ) ( ) Adults with good physical health. 85.4% 87.4% 89.7% 3 ( ) ( ) ( ) Adults with good to excellent overall health. 83.5% 82.9% 85.2% 2 ( ) ( ) ( ) Average number of days where poor mental or physical health interfered with activities of daily living in the past 30 days. 5.6% ( ) 2 5.2% ( ) 3.7% ( ) 153

155 HIV/AIDS Adults less than 65 years of age who had an HIV test in the past 12 months. 9.0% ( ) 1 7.0% ( ) 14.3% ( ) Adults less than 65 years of age who have ever been tested for HIV. 52.3% ( ) % ( ) 40.4% ( ) Hypertension Awareness & Control Adults with diagnosed hypertension. 31.6% 34.3% 32.6% 1 ( ) ( ) ( ) Adults with hypertension who currently take high blood pressure medicine. 82.6% ( ) 82.8% ( ) 81.7% ( ) Immunization Adults age 65 and older who have ever received a pneumonia vaccination. 76.2% ( ) % ( ) 68.5% ( ) Adults age 65 and older who received a flu shot in the past year. 72.9% ( ) % ( ) 73.0% ( ) Adults who have ever received a pneumonia vaccination. 34.2% 30.6% 30.5% 2 ( ) ( ) ( ) Adults who received a flu shot in the past year. 43.3% 36.5% 37.9% 1 ( ) ( ) ( ) Injury Prevention Adults 45 older who had a fall-related injury in the past 3 months. 4.6% ( ) 1 5.7% ( ) Adults who "always" or "nearly always" used seat belts when driving or riding in a car. 95.8% ( ) % ( ) Adults who, in the past 30 days, drove a vehicle after consuming too many alcoholic beverages. 2.7% ( ) 1.9% ( ) Overweight & Obesity Adults who are obese. 27.3% 27.2% 23.9% 2 ( ) ( ) ( ) Adults who are overweight. 34.1% 37.8% 39.8% 1 ( ) ( ) ( ) Adults who are overweight or obese. 61.4% 65.0% 63.7% 1 ( ) ( ) ( ) Adults who have a healthy weight (BMI from 18.5 to 24.9). 36.5% 33.4% 35.2% 1 ( ) ( ) ( ) Tobacco Use & Exposure Adult current smokers who tried to quit smoking at least once in the past year. 64.2% ( ) % ( ) 50.8% ( ) 154

156 Adults who are current smokers. 25.5% 17.1% 19.6% 4 ( ) ( ) ( ) Adults who are former smokers. 33.7% 29.8% 33.8% 1 ( ) ( ) ( ) Adults who have never smoked. 40.9% 53.0% 46.6% 4 ( ) ( ) ( ) 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. 155

157 Appendix B Charlotte County Data Demographic and Socioeconomic Characteristics This section provides a brief overview of some of the characteristics and trends that make Charlotte County unique in comparison to the state of Florida. Population Demographics Charlotte County, which has a population of approximately 161,100, is located in southwest Florida (Figure C-1). The county also shares borders with the following counties: Sarasota to the northwest; DeSoto to the north; Highlands to the northeast; Glades to the east; Hendry to the southeast; and Lee to the south. As seen in Figure C-2, Charlotte 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). Punta Gorda is the county seat and the only incorporated city. Charlotte County is square miles in area; 19 percent of that area is covered by water. The county has a population density of about 235 persons per square mile compared to a state average of 357 persons per square mile. Figure C-1: Figure C-2: 156

158 Population Growth The illustration below represents the total population of Charlotte County from The estimate for 2012 places the population of Charlotte County at 161,110. This represents a 19 percent increase since , , , , ,000 86,000 66,000 46,000 26,000 Chart C-1: Total Population Charlotte County , , , , , , , , , , , , , , , 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 Charlotte County is expected to continue to grow in the coming years. In 2016, it is estimated that the population of Charlotte County will be 167,125; that is an increase of four percent from the same number for , , , , , , , , , , ,000 Chart C-2: Estimated Population Charlotte County , , , , , Source: The Florida Legislature, Office of Economic and Demographic Research 157

159 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, Charlotte County has a larger elder population, aged 65 and older, than the state as a whole (34.5% Charlotte vs. 18.0% State). The median age in Charlotte County is much higher than the state (55.9 Charlotte vs State). Chart C-3: Population Percentage by Age Group Charlotte and State, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research Gender There are more women than men in Charlotte County. 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 percent of the residents of Charlotte County are female while 48.5 percent are male; statewide the percentages are 51.1 percent female and 48.9 percent male Chart C-4: Charlotte Population by Sex Percent of Total Population, Charlotte State Male Female Source: The Florida Legislature, Office of Economic and Demographic Research 158

160 Race and Ethnicity 9.2 percent of the population of Charlotte County is non-white; compared to a statewide population comprised of 21.6 percent non-whites. Approximately 3.1 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 C-5: Charlotte Population by Race Percent of Total Population, 2012 Other, 3.1% Black, 6.1% White, 90.8% Source: The Florida Legislature, Office of Economic and Demographic Research Only six percent of the residents of Charlotte County identify as Hispanic; this is much lower than the state average. The vast majority of the people in Charlotte County who identify as Hispanic identify as white. Table C- 1: Race and Ethnicity, 2012 Charlotte State Hispanic Non-Hispanic Hispanic Non-Hispanic White 5.4% 85.4% White 21.2% 57.1% Black 0.4% 5.7% Black 1.2% 15.4% Other 0.3% 2.8% Other 0.8% 4.3% Total 6.1% 93.9% Total 23.2% 76.8% Source: The Florida Legislature, Office of Economic and Demographic Research 159

161 Socioeconomic Indicators Like the rest of Florida, Charlotte County was affected by the economic downturn. The unemployment rate jumped from 3.7 percent in 2000 to 11.9 percent in 2012; it is higher than the state rate of 8.6 percent. The percent of people living under the poverty level in Charlotte County 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 nearly as high in Charlotte County as for the state; that rate is 24.2 percent for Charlotte County compared to 25.1 percent for the Florida average. Table C- 2: Socioeconomic Indicators Charlotte County and State County County State 2012 Labor Force as a % of Pop. Aged % 50.9% 62.5% Personal Bankruptcy Filing Rate per 1, Unemployment Rate 3.7% 11.9% 8.6% Average Annual Wage $31,488 $42,446 Per Capita Personal Income $26,122 $35,161* $39,636* % Living Below Poverty Level 13.2%* 17.0%* % ages 0-17 living below Poverty 24.2%* 25.1%* Source: The Florida Legislature, Office of Economic and Demographic Research *2011 data More residents of Charlotte County who are aged 25 and older have received a high school diploma than the state average. A smaller percentage of people in Charlotte County have received a Bachelor s degree than the percentage of residents of Florida who have done the same. Table C- 3: Educational Attainment Persons aged 25 and older, Charlotte and State County State % High School graduate or higher 88.4% 85.5% % Bachelor's degree or higher 20.9% 26.0% Source: The Florida Legislature, Office of Economic and Demographic Research 160

162 As seen in Chart C-6, among working adults in Charlotte County the most common sectors of employment are: education and health services, retail trade, professional and business services, and leisure and hospitality. Chart C-6: Average Employment by Category Charlotte and State, 2012 Education & health services Retail trade Professional and business services Leisure & hospitality Financial activities Construction Other services Public administration Manufacturing Transportation, warehousing, & utilities Wholesale trade Information Agriculture, forestry, fishing & mining 7.5% 7.7% 6.1% 6.2% 6.0% 5.3% 4.9% 4.9% 4.1% 5.3% 4.0% 4.9% 2.1% 2.9% 1.4% 1.9% 0.5% 1.1% 13.8% 13.8% 12.6% 11.1% 12.0% 20.3% 21.5% 18.2% Charlotte State Source: Florida Legislature, Office of Economic and Demographic Research 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 161

163 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 Charlotte County currently ranked the 28 th healthiest out of 67 counties in Florida for Health Outcomes, and 18 th healthiest for Health Factors. Charlotte County was ranked 28 th 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, Charlotte County ranked 29 th healthiest of all of the Florida counties. Charlotte County had a high average number of mentally unhealthy days reported in past 30 days (age-adjusted) (4.8) compared to the state average (3.7) and the national benchmark (2.3). Charlotte County was ranked as the 20 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. Charlotte County ranked higher than the state average for adult smoking (percent of adults that report smoking at least 100 cigarettes and currently smoking) (24% Charlotte vs. 19% State), but lower rates of teen births (35 births to teen mothers, per 1,000 female population) compared to the state average (40 births). For clinical care, Charlotte County was ranked as the 7 th healthiest county. Clinical care includes data on the number of uninsured, primary care physicians, dentists, preventable hospital stays, diabetic screening, and mammography screening. Charlotte County ranked high in clinical care partly due to higher than average rates of diabetic and mammography screenings. For example, the percent of female Medicare enrollees that receive mammography screening in Charlotte County (76%) was higher than that of the state average (70%) and the national benchmark (73%). Social & economic factors, where Charlotte County ranked 22 nd 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 Charlotte County, the percent of adults without social/emotional support was 24 percent. This rate is slightly higher than that of the state (22%), and considerably higher than the national benchmark (14%). The violent crime rate per 100,000 population in Charlotte County was 299, which is lower than the state rate (614 per 100,000) but higher than the national benchmark (66 per 100,000). 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, Charlotte County ranked 26 th healthiest. Charlotte County had lower than average rates of daily fine particulate matter (7.0 micrograms per cubic meter) than the state average (8.4) and the national benchmark (8.8). The percent of the Charlotte County population who are low-income and do not live close to a grocery store (limited access to healthy foods) (12%) was higher than the state average (7%) and significantly higher than the national benchmark (1%). 162

164 County Health Rankings Definitions for each measure are listed on the next pages. Charlotte County Error Margin Florida National Benchmark* Health Outcomes 28 Mortality 28 Premature death 7,877 7,263-8,492 7,310 5,317 Morbidity 29 Poor or fair health 20% 14-27% 16% 10% Poor physical health days Poor mental health days Low birth weight 7.3% % 8.7% 6.0% Health Factors 18 Health Behaviors 20 Adult smoking 24% 20-28% 19% 13% Adult obesity 26% 23-29% 26% 25% Physical inactivity 22% 19-24% 24% 21% Excessive drinking 15% 12-18% 16% 7% Motor vehicle crash death rate Sexually transmitted infections Teen birth rate Clinical Care 7 Uninsured 23% 21-25% 25% 11% Primary care physicians** 1,525:1 1,439:1 1,067:1 Dentists** 2,298:1 2,095:1 1,516:1 Preventable hospital stays Diabetic screening 90% 86-93% 84% 90% Mammography screening 76% 73-80% 70% 73% Social & Economic Factors 22 High school graduation** 73% 71% Some college 55% 51-59% 59% 70% Unemployment 10.8% 10.5% 5.0% Children in poverty 24% 18-31% 25% 14% Inadequate social support 24% 19-28% 22% 14% Children in single-parent households 36% 31-41% 37% 20% Violent crime rate Rank (of 67) 163

165 Physical Environment 26 Daily fine particulate matter Drinking water safety 1% 3% 0% Access to recreational facilities Limited access to healthy foods** 12% 7% 1% Fast food restaurants 44% 44% 27% Source: County Health Rankings & Roadmaps. Available at Accessed October 2, *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 164

166 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 165

167 Healthy People 2020 Objectives Below is Charlotte County s Healthy People 2020 data with relation to selected objectives (comparing 2007 Behavioral Risk Factor Surveillance Survey data with 2010 data, available on page 219). Table C- 4: Healthy People 2020 Objectives Charlotte County 2010 Objective Measure Progress AOCBC-2. Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms. 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. 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. IID Increase the percentage of noninstitutionalized adults aged 65 years and older who are vaccinated against seasonal influenza. Percentage of adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 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. 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 age 65 and over who received a flu shot in the past year. 13.3% 18.5% 62.90% 54.10% 61.00% 56.30% 64.70% 69.30% 64.40% 64.80% 63.10% 57.50% 77.60% 62.40% 54.40% 71.00% 73.70% 60.90% 75.00% 58.20% 29.80% 30.90% 74.80% 74.80% Needs Improvement Needs Improvement Needs Improvement Progress Shown Needs Improvement Needs Improvement Needs Improvement Progress Shown Needs Improvement Needs Improvement Needs Improvement Needs Improvement 166

168 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 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) % 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 September 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]. Progress Shown Progress Shown Needs Improvement Needs Improvement Progress Shown 167

169 Death Rate The death rate for Charlotte County residents has been consistently lower than the state average. For the three-year period from , Charlotte County s death rate was five percent lower than the state s rate (647.3 per 100,000 Charlotte County vs State). The death rate for Charlotte County has been on the decline for the past twenty years, but has seen an increase since Chart C-7: Charlotte Death Rate over 20 Years Compared to State Age-Adjusted All Causes 3-Year Death Rate State Charlotte 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 Charlotte County is lower than that of whites (656.3 white population vs black population); this is the opposite of the death rates for blacks and whites across the state of Florida as a whole. From , the black population in Charlotte County had slightly higher rates of death due to stroke and diabetes than the white population. The white population had considerably higher rates of death due to chronic lower respiratory disease, suicide, and cirrhosis than the black population. The white population had death rates for chronic lower respiratory disease six times higher than the black population (42.0 white population vs. 6.7 black population) and death rates for cirrhosis nine times higher (18.4 white population vs. 2.0 black population). There have been no deaths due to suicide in the black population of Charlotte County over the last three years, while the white population had a rate of 21.5 per 100,000 during this time. 168

170 Cancer and heart disease were the leading causes of death for both whites and blacks. Table C- 5: Major Causes of Death and Race, Charlotte County 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 Diabetes Suicide Cirrhosis Motor Vehicle Crashes Kidney Disease 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 C-8: Major Causes of Death and Race, Charlotte County 3-Year Age-Adjusted Death Rates by Cause White Black All Races Source: Florida Department of Health, Office of Vital Statistics 169

171 Leading Causes of Death Mortality rates can be key indicators of the state of health of a community. A significant number of Charlotte County 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 C- 6 gives detailed information on the leading causes of death for residents of Charlotte County 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 Charlotte County, 324 of them died of cancer 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. 170

172 Table C- 6: Major Causes of Death For 2012 Charlotte County Age- Adjusted Death Rate Per 100,000 3-Year Age- Adjusted Death Rate Per 100,000 Cause of Death Deaths Percent of Total Deaths Crude Rate Per 100,000 YPLL < 75 Per 100,000 Under 75 ALL CAUSES 2, % ,665 HEART DISEASE % ,915 CANCER % ,749 CHRONIC LOWER RESPIRATORY DISEASE % STROKE % DIABETES % UNINTENTIONAL INJURY % INFLUENZA & PNEUMONIA % ALZHEIMER'S DISEASE % KIDNEY DISEASE % CIRRHOSIS % 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 171

173 The most frequent causes of death for people in Charlotte County are heart disease and cancer. Together they accounted for 48 percent of the deaths in Table C- 7, which compares the threeyear age-adjusted rates for Charlotte County with those for all of Florida, shows that the death rates in Charlotte County for stroke, unintentional injury and Alzheimer s disease are significantly lower than the state average. The death rate for Charlotte County is higher than the state average for chronic lower respiratory disease and influenza & pneumonia. Table C- 7: Major Causes of Death Charlotte and State County Florida Age-Adjusted Rate/100,000 Age-Adjusted Rate/100,000 Cause of Death All Causes Heart Disease Cancer Chronic Lower Respiratory Disease Stroke Diabetes Unintentional Injury Influenza & Pneumonia Alzheimer s Disease Kidney Disease Source: Florida Department of Health, Office of Health Statistics and Assessment Age-adjusted death rates are computed using the year 2000 standard population. 172

174 Chronic Diseases Heart Disease Heart disease is the leading cause of death in Charlotte County. As seen in Chart C-9, age-adjusted death rates from heart disease have primarily been on the decline for both Charlotte County and the state of Florida as a whole during this time period. Rates for Charlotte County are slightly lower than the state average. 300 Chart C-9: Deaths from Heart Disease Age-adjusted rate per 100,000, 3-Year Rates State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 173

175 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 Charlotte County, 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 (12.2% Charlotte vs. 10.2% State). Residents with lower annual incomes reported the highest rates. 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Chart C-10: Adults Who Ever Had a Heart Attack, Angina, or Coronary Heart Disease Percentage by Income, Charlotte County % 10.6% 9.9% <$25,000 $25,000-$49,999 $50,000 or More 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]. 174

176 Cancer Cancer is the second most common cause of death in Charlotte County. Chart C-11 gives a detailed look at the decline in deaths from all cancers across the last twenty years. The decline in Charlotte County is not as smooth as the decline at the state level, although it has been consistently lower in Charlotte than for the state as a whole. Despite a few higher years, the overall trend is mostly positive. In fact, Charlotte County had the twelfth lowest three-year rate of deaths from all cancers of all 67 counties in Florida for Chart C-11: Deaths from All Cancers Age-adjusted rate per 100,000, 3-Year Rates State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 175

177 Cancer incidence in Charlotte County has remained fairly consisted over the last twenty years, with a low of per 100,000 in and a high of in The most recent four years of data show a slight upward trend. 600 Chart C-12: Cancer Incidence Age-adjusted rate per 100,000, 3-Year Rates State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics Among the types of cancer, lung cancer causes the highest number of deaths in Charlotte County. The incidence of prostate cancer is nearly as high as the incidence of lung cancer in Charlotte County, but it is not nearly as deadly. Table C- 8: Common Types of Cancer Death Rate and Incidence, Charlotte County 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. 176

178 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 Charlotte County 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 (52.6% Charlotte vs. 57.1% State). The rate is lowest for those women who make under $25,000 annually. Chart C-13: Women 18 Years of Age or Older Who Received a Pap Test in the Past Year Percentage By Income, Charlotte County % 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 41.8% 51.1% 72.0% 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]. Women ages 40 years and older are recommended to receive a mammogram, an x-ray of the breast, annually to detect and/or diagnose breast cancer. A lower percentage of women 40 years or older in Charlotte County reported that they had received a mammogram than the state average (53.6% Charlotte vs. 61.9% State). Income played a significant factor; women with incomes below $25,000 annually had the lowest rates. Chart C-14: Women 40 Years of Age and Older Who Received a Mammogram in the Past Year Percentage By Income, Charlotte County % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% <$25,000 $25,000-$49,999 $50,000 or More 45.4% 52.0% 61.8% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 177

179 Residents of Charlotte County over the age of 50 indicated that they are more 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 (59.5% 2010 vs. 55.6% 2007), and more likely than adults in the rest of the state to have been screened (59.5% Charlotte vs. 56.4% State). Chart C-15: Percentage of Adults 50 Years of Age and Older Who Received a Sigmoidoscopy or Colonoscopy in the Past Five Years Percentage By Income, Charlotte County % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 48.4% 61.3% 63.3% 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]. There has been a decrease in the number of adults 50 years or older who indicated that they have received a blood stool test (12.2% 2010 vs. 18.1% 2007); this rate is lower than the average across the state (12.2% Charlotte vs. 14.7% State). A blood stool test is another means of detecting colorectal cancer. Adults with annual incomes between $25,000 and $49,999 had the lowest rates across Charlotte County (8.1%). Chart C-16: Percentage of Adults 50 Years of Age and Older Who Received a Blood Stool Test in the Past Year Percentage By Income, Charlotte County % 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 13.6% 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]. 8.1% 15.3% <$25,000 $25,000-$49,999 $50,000 or More 178

180 Diabetes Deaths rates for diabetes in Charlotte County are much lower than those for cancer and heart disease, but are still a health concern. The age-adjusted three-year rates have fluctuated over the last twenty years, from a low of 14.5 per 100,000 ( ) to a high of 21.3 per 100,000 ( ), and have remained lower than the state average for the most part until recently. 25 Chart C-17: Deaths from Diabetes Age-adjusted rate per 100,000, 3-Year Rates State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 179

181 Charlotte County has a slightly higher rate of adults diagnosed with diabetes than the state (11.2% Charlotte vs. 10.4% State). The number of men reporting a diabetes diagnosis has increased from 2007 (14.0% 2010 vs. 11.4% 2007), but the number of women reporting this chronic condition has decreased (8.7% 2010 vs. 13.3% 2007). 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% Chart C-18: Adults with Diagnosed Diabetes Percentage by Sex, 2007 and % 13.3% 12.4% 11.4% 11.7% 11.2% 10.4% 8.7% 9.2% 2007 Charlotte 2010 Charlotte 2010 Florida 4.0% 2.0% 0.0% Men Women Overall 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]. 180

182 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 13.6% rate in 2010, while those with incomes $50,000 or more only reported a 8.8% rate of diagnosed diabetes. 18.0% Chart C-19: Percentage of Adults with Diagnosed Diabetes Percentage By Income, Charlotte County % 14.0% 13.6% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 9.4% 8.8% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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 Charlotte County residents reported ever having participated in diabetes self-management education than the state as a whole (58.9% Charlotte vs. 55.1% State). 181

183 Communicable Diseases Charlotte County 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 C- 10: Communicable Diseases Charlotte County 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 182

184 Sexually Transmitted Diseases Chlamydia is the most prevalent sexually transmitted disease in Charlotte County with an average of cases per year between 2010 and That works out to a rate per 100,000 of 189.3; 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 Charlotte County have also seen a slight increase, but have remained well below the state rate over the past twenty years. For the three year period from Charlotte County ranked 2 nd lowest out of 67 counties in Florida for the rate of chlamydia cases per 100,000 population Chart C-20: Chlamydia Cases 3-Year Rate per 100, State Charlotte Source: Florida Department of Health, Bureau of STD Prevention & Control 183

185 Vaccine Preventable Diseases The overall rate of infection from vaccine preventable diseases is very low in Charlotte County. For most of these diseases there is an average of less than one case every three years. Hepatitis B, a contagious liver disease that results from infection with the Hepatitis B virus, is the most common vaccine preventable disease in Charlotte County with an average of 2.7 cases per year between 2010 and At a 3-year rate of 1.7 per 100,000, Charlotte County is seeing its highest rates in fifteen years, and rates higher than the state average for the first time since Chart C-21: Acute Hepatitis B Cases 3-Year Rate per 100, Florida Charlotte Source: Florida Department of Health, Bureau of Epidemiology 184

186 Pertussis, a highly contagious respiratory disease that is commonly known as whooping cough, is another vaccine preventable disease being seen more frequently in recent years in Charlotte County with an average of 0.7 cases per year between 2010 and At a 3-year rate of 1.0 per 100,000, Charlotte County has recently seen its highest rates in twenty years, fortunately there has not been a death attributed to pertussis in Charlotte County in at least forty years. 2.5 Chart C-22: Pertussis Cases 3-Year Rate per 100, State Charlotte Source: Florida Department of Health, Bureau of Epidemiology 185

187 AIDS and Other Diseases An average of 5.7 people per year was diagnosed with AIDS in Charlotte County between 2010 and The rate per 100,000 in Charlotte County is 3.5 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 Charlotte County residents has decreased 45 percent over the past decade (6.4 per 100,000 in vs. 3.5 per 100,000 in ), and is ranked the 4 th lowest county of all 67 counties for AIDS cases. 60 Chart C-23: AIDS Cases 3-Year Rate per 100, State Charlotte 0 Source: Florida Department of Health, Bureau of HIV/AIDS The rate of tuberculosis, an infectious bacterial disease, in Charlotte County is lower than the state as a whole at 1.7 per 100,000 compared to 2.9 per 100,000. Charlotte County had a 3-year high of 3.1 per 100,000 in , and has seen a fairly steady decline in the years since. 12 Chart C-24: Tuberculosis Cases 3-Year Rate per 100, State Charlotte Source: Florida Department of Health, Bureau of TB and Refugee Health 186

188 Maternal and Child Health On average, 1,011.7 babies were born per year in Charlotte County between 2010 and 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 Charlotte County 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. Infant mortality rates for this time period in Charlotte County are lower than the average for the state of Florida, and continue to decline. Table C- 11: Maternal & Child Health Indicators, Charlotte County & State 3-Year Figures, Births County State Trend Quartile* Total Births (3-yr annual avg.) 1,011.7 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 2 Percent of Births to Unwed Mothers Negative 3 Infant Deaths Infant Deaths (0-364 days) per 1,000 Births Positive 1 Neonatal Deaths (0-27 days) per 1,000 Births Positive 1 Postneonatal Deaths ( days) per 1,000 Births Positive 2 Low Birth Weight Percent of Births < 1500 Grams Negative 2 Percent of Births < 2500 Grams Negative 3 Prenatal Care Percent of Births with 1st Trimester Prenatal Care Steady 2 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. 187

189 Teen Births In the 3-year period from 2010 through 2012, Charlotte County saw its lowest rates of live births to teenage and pre-teen mothers (15.8 births per 1,000). Charlotte County had rates of teen births consistently lower than the rates for the state of Florida until Rates for both the state and Charlotte County have been declining. 35 Chart C-25: Births to Mothers ages Year Rate per 1, State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 188

190 Infant Deaths Infant deaths in Charlotte County have declined consistently since the most recent peak in (7.8 per 1,000 births). There were thirteen infant deaths in 2012 (4.3 per 1,000 births) Chart C-26: Infant Deaths (0-364 days) 3-Year Rate per 1, State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 189

191 Mothers Who Smoked During Pregnancy Charlotte County s rates have been consistently higher than that of the state. For the 3-year period from 2010 through 2012, Charlotte County had a rate of 14.7 births per 1,000 to mothers who smoked during pregnancy, as compared to the state average of 6.8 births per 1,000. This rate has seen a 47 percent decrease over the past twenty years, from a high of 27.9 births per 1,000 to mothers who smoked during pregnancy for to its current rate of 14.7 births per 1,000 for Chart C-27: Births to Mothers who Smoked During Pregnancy 3-Year Rate per 1, State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics 190

192 Oral Health According to the Behavioral Risk Factor Surveillance System 2010 Data Report (available on page 219), a larger percentage of adults in Charlotte County reported that they had visited a dentist or dental clinic in the past year than the same for the state (71.3% Charlotte vs. 64.7% State). Women were more likely than men to have reported a visit to a dentist of dental clinic (68.3% men vs. 74.0% women). Persons in Charlotte County 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 while only 55.5 percent of those with incomes under $25,000 annually only reported the same. Chart C-28: Adults Who Visited a Dentist or Dental Clinic in the Past Year Percentage By Income, Charlotte County % 80.9% 81.3% 80.0% 70.0% 60.0% 55.5% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 191

193 Charlotte County residents reported higher rates of having a permanent tooth removed because of tooth decay or gum disease than adults across the state (61.2% Charlotte vs. 53.0% State). Income levels, again, played a role in the percentage of these procedures amongst Charlotte County residents. Chart C-29: Adults Who Had a Permanent Tooth Removed Because of Tooth Decay or Gum Disease Percentage By Income, Charlotte County % 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 71.1% 60.3% 55.6% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 192

194 Overall 63.0 percent of Charlotte County 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. 90.0% 80.0% 70.0% Chart C-30: Adults Who Had Their Teeth Cleaned in the Past Year Percentage By Income, Charlotte County % 66.8% 60.0% 50.0% 44.7% 40.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 193

195 Accessibility for Low-Income Residents According to data from the Florida Department of Health Public Health Dental Program, Charlotte County residents who are living below the poverty level have seen in increase in their access to dental care over recent years. Charlotte County s rates have remained consistently lower than the state of Florida as a whole, but are only slightly lower for the 3-year period from 2008 through 2010 (25.2% Charlotte vs. 31.5% State). 35 Chart C-31: Percentage of Low-Income Persons* with Access to Dental Care 3-Year Rate State Charlotte Source: Florida Department of Health, Public Health Dental Program *Low-Income Persons are defined as those living below the poverty level. 194

196 Dental Emergencies A lack of access to dental care can lead to avoidable visits to the local emergency room and avoidable hospitalizations. In 2012, Charlotte County hospitals received 584 emergency room visits for dental conditions that are typically considered avoidable with appropriate preventive care. The charges for these avoidable visits totaled $945,693. Table C- 12: Avoidable Emergency Department Visits for Dental Conditions as Patient s Reason for Visit Charlotte County Hospitals, April 2012 through March 2013 Facility Total Emergency Department Visits* Average Charges Total Charges CHARLOTTE REGIONAL MEDICAL CENTER 117 $969 $113,417 FAWCETT MEMORIAL HOSPITAL 220 $2,534 $557,578 PEACE RIVER REGIONAL MEDICAL CENTER 247 $1,112 $274,698 TOTAL 584 $1,619 $945,693 Source: Florida Health Finder Emergency Department Query. Available at Accessed October 8, *The data shown does not include emergency department visits that resulted in an admission to the hospital. Preventable hospitalizations for Charlotte County residents under 65 years of age have fluctuated over the last several years, trending upward. The most recent 3-year rate per 100,000 ( ) was above the Florida rate (11.4 Charlotte vs. 9.9 State). Chart C-32: Preventable Hospitalizations Under 65 from Dental Conditions 3-Year Rate per 100, State Charlotte Source: Florida Agency for Health Care Administration (AHCA) 195

197 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 Charlotte County ranks amongst the best quartile for crime in the state of Florida. Charlotte County ranks below the state average for all categories of crime and domestic violence, and ranks in the 1 st Quartile for total domestic violence offenses, aggravated assault, motor vehicle theft, forcible sex offenses and murder. Table C- 13: Charlotte County Crime and Domestic Violence 3-Year Rate per 100,000, County State Quartile* Larceny 1, , Burglary Total Domestic Violence Offenses 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 Charlotte County. These rates, although high, have seen a decline from a recent high in of 2,238.3 per 100,000 population Chart C-33: Larceny in Charlotte County 3-Year Rate Per 100,000 Population State Charlotte Source: Florida Department of Law Enforcement 196

198 Burglary, also called breaking and entering, had the second highest rates of all of the crime and domestic violence indicators in Charlotte County. These rates have remained fairly steady over the last twenty years, but consistently lower than the state rates Chart C-34: Burglary in Charlotte County 3-Year Rate Per 100,000 Population State Charlotte Source: Florida Department of Law Enforcement 197

199 Alcohol-related Motor Vehicle Crashes In 2011 Charlotte County residents were involved in 1,319 motor vehicle traffic crashes. Of these, 7.1 percent (94 crashes) were alcohol-related. In that same year there were 24 motor vehicle traffic crash deaths; 21 percent (5 deaths) were alcohol-related. 40 Chart C-35: Motor Vehicle Crash Deaths in Charlotte County Total Deaths and Alcohol-related Deaths, Motor Vehicle Crash Deaths Alcohol-related Motor Vehicle Traffic Crash Deaths 5 0 Source: Florida Department of Health, Bureau of Vital Statistics, and Florida Department of Highway Safety and Motor Vehicles Charlotte County had rates lower or equal to the state average for all of the alcohol-related motor vehicle crash indicators for the three year period from 2009 to Charlotte County ranked in the 1 st Quartile for each indicator. Table C- 14: Charlotte County 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. 198

200 The percent of adults who reported on the Behavioral Risk Factor Surveillance System survey that they engage in heavy or binge drinking in Charlotte County decreased from 14.9 percent in 2007 to 12.3 percent in This percentage is lower than the state average of 15.0 percent. The rate of heavy and binge drinking is higher for men than for women in Charlotte County (15.0 men vs women). Persons with higher income levels reported drinking at higher rates than those with lower annual incomes. In fact, more than double the number of Charlotte County 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. Chart C-36: Percentage of Adults who Engage in Heavy or Binge Drinking Percentage By Income, Charlotte County % 22.9% 20.0% 15.0% 10.0% 10.7% 10.4% 5.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 199

201 Florida Youth Substance Abuse Survey 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 Charlotte County, 898 students completed the survey (458 middle school students; 440 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 26.6 percent for Charlotte County students in 2012, which was slightly higher than the state average of 24.6 percent had the lowest percentage of Charlotte County students reporting that they had used alcohol in the past 30 days in the years surveyed, with a high of 42.2 percent in % Chart C-37: Past-30-Day Alcohol Use Charlotte County and Florida Statewide % 40.0% 30.0% 20.0% 10.0% 0.0% Middle School High School Overall 2002 Charlotte 2004 Charlotte 2006 Charlotte 2008 Charlotte 2010 Charlotte 2012 Charlotte 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 200

202 The percentage of students reporting cigarette use over the past 30 days in Charlotte County in 2012 was higher than the Florida average (12.8% Charlotte vs. 6.6% State). This rates has fluctuated over the past years, but has decreased 38 percent since Males are more likely to report cigarette use than females (13.0% males vs. 11.6% females). 30.0% Chart C-38: Past-30-Day Cigarette Use Charlotte County and Florida Statewide % 20.0% 15.0% 10.0% 5.0% 0.0% Middle School High School Overall 2002 Charlotte 2004 Charlotte 2006 Charlotte 2008 Charlotte 2010 Charlotte 2012 Charlotte 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Past-30-day marijuana use for Charlotte County students in 2012 was higher than students across the state as a whole (16.5% Charlotte vs. 12.4% State). The overall percentage of Charlotte County students who have reported marijuana use has fluctuated over recent years,but has decreased 24 percent since High school students surveyed were nearly three times as likely to have used marijuana as middle school students (22.0% high school students vs. 8.4% middle school students). 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Chart C-39: Past-30-Day Marijuana Use Charlotte County and Florida Statewide 2012 Middle School High School Overall 2002 Charlotte 2004 Charlotte 2006 Charlotte 2008 Charlotte 2010 Charlotte 2012 Charlotte 2012 Florida Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families 201

203 The FYSAS asks youth if they have ever used various drugs. Table C- 15 below illustrates the high incidence of youth having ever tried alcohol, cigarettes, and marijuana in particular. Also relatively high were the percentage of Charlotte County high school students in 2012 who reported having ever used synthetic marijuana (22.8%), and the percentage of middle school students who reported having ever used inhalants (10.3%). These rates are higher than Florida s statewide averages for the same substances. Table C- 15: Percentages of Youth Who Reported Having Used Various Drugs in their Lifetimes 2012 Charlotte County Middle High School 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 Past 30-day drug use is detailed in Table C- 16 and Table C

204 Table C- 16: Percentages of Youth Who Reported Having Used Various Drugs in the Past 30 Days 2012 Charlotte County Florida Statewide Middle High Ages Ages Middle High Ages Ages School School Female Male Overall School School Female Male Overall Alcohol Binge Drinking 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 Any illicit drug Any illicit drug other than marijuana Alcohol only Alcohol or any illicit drug Any illicit drug, but no alcohol Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Note: The first 16 rows show results for alcohol, cigarettes, and other drugs. The last five data rows show results for various combinations of drugs. Binge drinking is defined as having had five or more alcoholic drinks in a row in the past two weeks. Ecstasy, Rohypnol, GHB and ketamine are provided as examples in the question about club drugs. Table C- 17: Past 30-day Trend in Alcohol, Tobacco and Other Drug Use for Charlotte County Youth 2002, 2004, 2006, 2008, 2010 and Middle High Middle High Middle High Middle High Middle High Middle High School School Overall School School Overall School School Overall School School Overall School School Overall School School Overall Alcohol Binge Drinking Cigarettes Marijuana or Hashish 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 Any illicit drug Any illicit drug other than marijuana Alcohol only Alcohol or any illicit drug Any illicit drug, but no alcohol Source: Florida Youth Substance Abuse Survey (2012), Florida Department of Children and Families Note: The first 15 rows show results for alcohol, cigarettes, and other drugs. The last five data rows show results for various combinations of drugs. Binge drinking is defined as having had five or more alcoholic drinks in a row in the past two weeks. Ecstasy, Rohypnol, GHB and ketamine are provided as examples in the question about club drugs. 203

205 Suicides The suicide rate for Charlotte County has been on the rise over the last twenty years, increasing about thirty-three percent since 1993 ( vs ). The most recent 3-year rate per 100,000 is well above the state average (19.9 Charlotte vs State). Of the 67 counties in Florida, Charlotte County ranked 11 th highest for the age-adjusted suicide death rate. 25 Chart C-40: Age-Adjusted Suicide Death Rate 3-Year Rate Per 100,000 Population State Charlotte Source: Florida Department of Health, Bureau of Vital Statistics. 204

206 Baker Act There were 1,058 involuntary examinations in Charlotte County in This number has nearly doubled since 2002 (544 involuntary examinations). The rate per 100,000 of the population in Charlotte County that was given an involuntary exam in 2012 was lower than the state rate (656.7 Charlotte vs State). Of those in Charlotte County, percent were initiated by law enforcement, percent were initiated by mental health professionals, and 1.32 percent were initiated by judges. 900 Chart C-41: Involuntary Examinations* Single Year Rate Per 100,000 Population State Charlotte 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. 205

207 Hospitalizations Prevention Quality Indicators Congestive heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease (this category includes chronic bronchitis and emphysema) are the most common preventable causes of hospitalizations for Charlotte County residents. Charlotte County s 2012 rates of hospitalizations due to chronic obstructive pulmonary disease, congestive heart failure, bacterial pneumonia, angina without procedure and adult asthma were higher than the state of Florida as a whole. Since 2007, rates of lower extremity amputations of diabetic patients have nearly doubled ( vs ) and rates of diabetes short-term complications have increased by 67 percent ( vs ). Rates of hospitalizations due to dehydration have decreased by 59 percent ( vs ). Table C- 18: Prevention Quality Indicators Annual Rate per 100, , Charlotte County 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 Charlotte County residents in any hospital in Florida. 206

208 Chronic Conditions Hypertension is the number one cause of hospitalization for a chronic condition. The number of hospitalizations for hypertension has fluctuated within a fairly thin margin over the last few years. The hospitalization rates for diabetes, congestive heart failure, and sickle cell are on the rise. Table C- 19: Hospitalizations for Chronic Conditions Annual Figures, , Charlotte County Residents Disease Diabetes 5,715 5,745 6,342 6,215 6,406 Asthma Congestive Heart Failure Hypertension AIDS Sickle Cell 2,038 1,904 2,163 2,076 1,896 4,020 4,150 4,487 4,276 4,317 11,719 11,802 12,353 11,725 11, Source: AHCA via Broward Regional Health Planning Council Hospital Inpatient and Emergency Department Analytical System Includes hospitalizations of Charlotte County residents in any hospital in Florida. 207

209 Emergency Room Visits Charlotte County residents made 50,439 visits to hospitals in 2012 that did not result in an inpatient admission. The largest number of visits was made to Peace River Regional Medical Center. The next largest numbers of visits were made to Fawcett Memorial Hospital, Charlotte Regional Medical Center, and Englewood Community Hospital. Table C- 20: Emergency Room Visits by Charlotte County Residents by Payer Source 2012 Medicaid Medicare No charge/ Charity Other Private, incl. HMO Self- Pay* Grand Total Peace River Regional Medical Center 6,738 2, ,685 2,228 14,667 Fawcett Memorial Hospital 2,562 5, ,476 1,721 12,984 Charlotte Regional Medical Center 3,069 3, ,777 1,514 10,227 Englewood Community Hospital 1,311 2, , ,025 Sarasota Memorial Hospital 1, ,523 Venice Regional Medical Center Lee Memorial Hospital Healthpark Medical Center DeSoto Memorial Hospital Cape Coral Hospital Doctors Hospital Of Sarasota All Children's Hospital Inc Gulf Coast Medical Center University Community Hospital Manatee Memorial Hospital Tampa General Hospital Lakewood Ranch Medical Center Shands Hospital at The Univ. Of Florida Bayfront Medical Center Inc Total 15, % 14, % % 2, % 9, % 7, % 50, % 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 Charlotte County 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 30 visits are included in the chart above. There are an additional 831 visits divided amongst 164 hospitals that have not been included in the chart, but are included in the total. 208

210 Health Resources 21.2 percent of adults in Charlotte County 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 worse than the state average of 17.3 percent. More Charlotte County women reported not being able to see a doctor in the past year due to cost than men in Chart C-42: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Sex, Charlotte County % 20.0% 15.0% 10.0% 9.6% 19.1% 15.4% 16.5% 23.0% 19.1% 13.3% 21.2% 17.3% 2007 Charlotte 2010 Charlotte 2010 Florida 5.0% 0.0% Men Women Overall 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]. 209

211 Annual income and age had the greatest effect in Charlotte County residents ability to see a doctor. Residents with annual incomes $25,000 or more only reported not being able to see a doctor due to cost at rates of 14.5 to 15 percent, while those with annual incomes below $25,000 reported a rate of 41.4 percent. Chart C-43: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Income, Charlotte County % 40.0% 35.0% 30.0% 25.0% 41.4% 20.0% 15.0% 14.5% 15.0% 10.0% 5.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 210

212 Older Charlotte County residents had significantly less difficulty seeing a doctor than their younger counterparts. Chart C-44: Percentage of Adults who Could Not See a Doctor at Least Once in the Past Year Due to Cost Percentage by Age, Charlotte County % 40.0% 35.0% 30.0% 40.6% 25.0% 20.0% 21.8% 15.0% 10.0% 5.0% 0.0% 3.2% & Older 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]. 211

213 73.5 percent of adults in Charlotte County reported that they had a medical checkup in the past year; this is worse than the state average of 69.7 percent. Annual income played a role in how likely Charlotte County residents were to have had a medical checkup. Those with annual incomes of $50,000 or more had the highest rates (82.2%) of all income groups. 90.0% 80.0% 70.0% 60.0% Chart C-45: Percentage of Adults who had a Medical Checkup in the Past Year Percentage by Income, Charlotte County % 80.3% 82.2% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% <$25,000 $25,000-$49,999 $50,000 or More 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]. 212

214 Medicaid As of 2011, approximately 12,000 out of every 100,000 people in Charlotte County 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. Charlotte County has the 9 th lowest Medicaid enrollment rates out of the 67 counties in Florida Chart C-46: Median Monthly Medicaid Enrollment Single-Year Rate Per 100,000 Population State Charlotte Source: Florida Department of Health, Office of Planning, Evaluation & Data Analysis 213

215 Florida 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 C- 21: Monthly Children s Health Insurance Enrollment Charlotte County Florida Healthy Kids MediKids CMS Total Active Children September, , ,972 October, , ,953 November, , ,988 December, , ,973 January, , ,942 February, , ,960 March, , ,980 April, , ,949 May, , ,975 June, , ,965 July, , ,948 August, , ,964 Source: Florida Healthy Kids Corporation 2,000 1,990 1,980 1,970 1,960 1,950 1,940 1,930 1,920 1,910 Chart C-47: Total Monthly Children s Health Insurance Enrollment Charlotte County Source: Florida Healthy Kids Corporation 214

216 Uninsured As of 2011, Charlotte County was estimated as having 25.5 percent of adults without health insurance; this compares to a rate of 29.3 percent for Florida as a whole. This number is a 5.6 percent decrease from % Chart C-48: Uninsured Adults (Age 18 64) % 29.0% 28.0% 27.0% 26.0% 25.0% Charlotte State 24.0% 23.0% 22.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 215

217 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, 50.8 percent of Charlotte County adults with incomes at or below 138% of the Federal Poverty Level (FPL) were uninsured. Charlotte County adults with incomes above 400% of the FPL only had a rate of 8.3 percent being without health insurance. Chart C-49: Uninsured Adults (Age 18 64) Percentage by Income (based on Federal Poverty Level), Charlotte County % 27.3% 8.3% 25.5% <=138% of Poverty 139% - 400% of Poverty >400% of Poverty Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) All Incomes Insured Uninsured 216

218 While the percentage of adults who are uninsured has increased slightly since 2009, rates of uninsured Charlotte County residents under the age of 19 continue to decline. Since 2006, the number of uninsured youth has decreased 37.4 percent to a low of 12.7 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 % Chart C-50: Uninsured Youth (Under 19 Years) % 15.0% 10.0% Charlotte State 5.0% 0.0% Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) As with the adult population in Charlotte County, youth living in households with income levels near and below the Federal Poverty Level had the highest rates of being uninsured Chart C-51: Uninsured Youth (Under 19 Years) Percentage by Income (based on Federal Poverty Level) Charlotte County Insured Uninsured % 12.6% 4.4% 12.7% <=138% of Poverty 139% - 400% of Poverty >400% of Poverty All Incomes Source: The Census Bureau s Small Area Health Insurance Estimates (SAHIE) 217

219 Physicians and Facilities As of 2011, there were three hundred and fifty-five licensed physicians in Charlotte County. That works out to 221 doctors for every 100,000 residents. That is a 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 (9.3 Charlotte vs State). The number of Charlotte County Health Department employees per every 100,000 residents is higher than the state average. The Charlotte County Health Department spent $7,698,218 dollars in 2011; that places the rate of expenditure per 100,000 residents at slightly higher than the state average. Providers* Table C- 22: Health Resources Availability Charlotte County & State 2011 County Rate per Number 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 1, County Health Department County Health Department Full-Time Employees County Health Department Expenditures $7,698,218 $4,792,456 2 $4,204,339 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. 218

220 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 Charlotte County 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. 12.3% 15.0% 14.9% 1 ( ) ( ) ( ) Arthritis Adults who are limited in any way in any usual activities because of arthritis or chronic joint symptoms. 15.4% ( ) 14.9% ( ) 14.6% ( ) Adults who have been told they have some form of arthritis. 39.6% 32.0% 32.7% ( ) ( ) ( ) Asthma Adults who currently have asthma. 7.2% 8.3% 6.3% 1 ( ) ( ) ( ) Cancer Screening Adults 50 years of age and older who received a blood stool test in the past year. 12.2% ( ) % ( ) 18.1% ( ) Adults 50 years of age and older who received a sigmoidoscopy or colonoscopy in the past five years. 59.5% ( ) % ( ) 55.6% ( ) Adults ages 50 years and older who have ever had a blood stool test. 40.4% ( ) % ( ) 43.2% ( ) Adults ages 50 years and older who have ever had a sigmoidoscopy or colonoscopy. 73.8% ( ) % ( ) 65.8% ( ) Men 45 years of age and older who have been told they have prostate cancer. 17.4% ( ) 4 7.3% ( ) Men ages 50 years and older who have ever had a digital rectal exam. 84.9% ( ) % ( ) 86.2% ( ) Men ages 50 years and older who have ever had a PSA test. 89.5% 85.0% 85.7% 1 ( ) ( ) ( ) 219

221 Women 18 years of age and older who received a Pap test in the past year. 52.6% ( ) % ( ) 59.6% ( ) Women 40 years of age and older who received a mammogram in the past year. 53.6% ( ) % ( ) 64.1% ( ) Women ages 40 years and older who had a clinical breast exam in the past year. 58.7% ( ) % ( ) 63.6% ( ) Women who have had a hysterectomy. 32.0% 26.2% 3 ( ) ( ) Cardiovascular Disease Adults who have ever had a heart attack, angina, or coronary heart disease. 12.2% ( ) % ( ) 13.4% ( ) Adults who have ever had a stroke. 2.8% 3.5% 3.9% 1 ( ) ( ) ( ) Cholesterol Awareness Adults who have diagnosed high blood cholesterol. 43.4% 38.6% 46.2% ( ) ( ) ( ) Dental Care Adults who had a permanent tooth removed because of tooth decay or gum disease. 61.2% ( ) % ( ) Adults who had their teeth cleaned in the past year. 63.0% 60.9% 1 ( ) ( ) Adults who visited a dentist of dental clinic in the past year. 71.3% 64.7% 1 ( ) ( ) Diabetes Adults with diabetes who ever had diabetes self-management education. 58.9% ( ) % ( ) 64.0% ( ) Adults with diabetes who had an annual eye exam. 71.4% 70.2% 83.6% 2 ( ) ( ) ( ) Adults with diabetes who had an annual foot exam. 69.8% 72.2% 72.0% 3 ( ) ( ) ( ) Adults with diabetes who had two A1C tests in the past year. 70.4% % 69.2% ( ) ( ) ( ) Adults with diagnosed diabetes. 11.2% 10.4% 12.4% 2 ( ) ( ) ( ) Disability Adults who are limited in any way in any activities because of physical, mental, or emotional problems. 26.2% ( ) % ( ) 21.4% ( ) 220

222 Adults who use special equipment because of a health problem. 9.0% ( ) 2 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. 64.3% ( ) 56.2% ( ) Health Care Access & Coverage Adults who could not see a doctor at least once in the past year due to cost. 21.2% ( ) % ( ) 13.3% ( ) Adults who had a medical checkup in the past year. 73.5% 69.7% 75.1% 1 ( ) ( ) ( ) Adults who have a personal doctor. 85.1% 81.7% 84.4% 1 ( ) ( ) ( ) Adults who think they would get better medical care if they belonged to a different race/ethnic group. 6.9% ( ) 10.8% ( ) Adults with any type of health care insurance coverage. 87.4% 83.0% 86.5% 1 ( ) ( ) ( ) Health Status & Quality of Life Adults who always or usually receive the social and emotional support they need. 80.7% ( ) % ( ) 77.5% ( ) Adults who had poor mental health on 14 or more of the past 30 days. 13.6% ( ) % ( ) 8.8% ( ) Adults who had poor physical health on 14 or more of the past 30 days. 15.6% ( ) % ( ) 12.4% ( ) Adults who said their overall health was "fair" or "poor". 21.2% 17.1% 16.8% 3 ( ) ( ) ( ) Adults whose poor physical or mental health kept them from doing usual activities on 14 or more of the past 30 days. 13.7% ( ) % ( ) 15.7% ( ) Adults with good mental health. 86.4% 88.2% 91.2% 3 ( ) ( ) ( ) Adults with good physical health. 84.4% 87.4% 87.6% 3 ( ) ( ) ( ) Adults with good to excellent overall health. 78.8% 82.9% 83.2% 3 ( ) ( ) ( ) Average number of days where poor mental or physical health interfered with activities of daily living in the past 30 days. 5.1% ( ) 2 5.2% ( ) 5.0% ( ) 221

223 HIV/AIDS Adults less than 65 years of age who had an HIV test in the past 12 months. 12.2% ( ) 1 7.0% ( ) 10.6% ( ) Adults less than 65 years of age who have ever been tested for HIV. 44.9% ( ) % ( ) 48.9% ( ) Hypertension Awareness & Control Adults with diagnosed hypertension. 37.1% 34.3% 34.4% 3 ( ) ( ) ( ) Adults with hypertension who currently take high blood pressure medicine. 81.6% ( ) 82.8% ( ) 86.4% ( ) Immunization Adults age 65 and older who have ever received a pneumonia vaccination. 75.6% ( ) % ( ) 66.7% ( ) Adults age 65 and older who received a flu shot in the past year. 67.5% ( ) % ( ) 70.1% ( ) Adults who have ever received a pneumonia vaccination. 37.7% 30.6% 36.0% 1 ( ) ( ) ( ) Adults who received a flu shot in the past year. 46.3% 36.5% 45.2% 1 ( ) ( ) ( ) Injury Prevention Adults 45 older who had a fall-related injury in the past 3 months. 4.3% ( ) 1 5.7% ( ) Adults who "always" or "nearly always" used seat belts when driving or riding in a car. 96.2% ( ) % ( ) Adults who, in the past 30 days, drove a vehicle after consuming too many alcoholic beverages. 0.3% ( ) 1.9% ( ) Overweight & Obesity Adults who are obese. 21.7% 27.2% 24.0% 1 ( ) ( ) ( ) Adults who are overweight. 33.9% 37.8% 35.6% 1 ( ) ( ) ( ) Adults who are overweight or obese. 55.6% 65.0% 59.6% 1 ( ) ( ) ( ) Adults who have a healthy weight (BMI from 18.5 to 24.9). 41.9% 33.4% 36.9% 1 ( ) ( ) ( ) Tobacco Use & Exposure Adult current smokers who tried to quit smoking at least once in the past year. 41.1% ( ) % ( ) 51.2% ( ) 222

224 Adults who are current smokers. 20.7% 17.1% 22.9% 2 ( ) ( ) ( ) Adults who are former smokers. 32.9% 29.8% 31.3% 2 ( ) ( ) ( ) Adults who have never smoked. 46.4% 53.0% 45.8% 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. 223

225 Appendix C Hendry County Data Demographic and Socioeconomic Characteristics This section provides a brief overview of some of the characteristics and trends that make Hendry County unique in comparison to the state of Florida. Population Demographics Hendry County, which has a population of just fewer than 39,000, is located in southwest Florida (Figure H-1). The county also shares borders with the following counties: Glades to the north; Martin and Okeechobee to the northeast; Palm Beach to the east; Broward to the southeast; Collier to the south; and Lee and Charlotte to the west. As seen in Figure H-2, Hendry 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). LaBelle is the county seat. Clewiston is the largest and most populous incorporated area. Hendry County is 1, square miles in area; about 3 percent of that area is covered by water. The county has a population density of about 34 persons per square mile compared to a state average of 357 persons per square mile. Hendry County is considered a rural county. Figure H-1: Figure H-2: 224

226 Population Growth The illustration below represents the total population of Hendry County from The estimate for 2012 places the population of Hendry County at 38,537. This represents a 12 percent increase since ,000 40,000 38,000 36,000 34,000 32,000 30,000 28,000 26,000 34,533 35,608 Chart H-1: Total Population Hendry County ,300 36,135 36,148 36,347 37,139 38,219 38,732 39,036 39,165 39,103 40,955 38,871 38, 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 Hendry County is expected to continue to grow in the coming years. In 2016, it is estimated that the population of Hendry County will be 38,758; that is an increase of just under one percent from the same number for ,000 38,500 Chart H-2: Estimated Population Hendry County ,537 38,381 38,390 38,535 38,758 38,000 37,500 37,000 36,500 36, Source: The Florida Legislature, Office of Economic and Demographic Research 225

227 Age The largest proportion of the population of the county is between the ages of 25 and 44 while the largest proportion of the population for the state is between 45 and 64. Hendry County has a smaller elder population, aged 65 and older, than the state as a whole (12.3% Hendry vs. 18.0% State). The median age in Hendry County is lower than the state (32.8 Hendry vs State). Chart H-3: Population Percentage by Age Group Hendry and State, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research Gender There are significantly more men than women in Hendry County percent of the residents of Hendry County are male while 46.9 percent are female; statewide the percentages are 51.1 percent female and 48.9 percent male. Nationwide females outnumber males, but it is not uncommon for men to outnumber women in rural areas. Chart H-4: Hendry Population by Sex Percent of Total Population, 2012 Source: The Florida Legislature, Office of Economic and Demographic Research 226