Community Health Needs Assessment 2015

Transcription

1 Community Health Needs Assessment 2015 March 4, 2015

2 Table of Contents Page EXECUTIVE SUMMARY... i I. Introduction and Mission... 1 II. A Retrospective Review... 2 III. Summary Observations from the Current CHNA... 4 IV. Community Description... 6 V. Information Sources & Data Collection Approaches... 9 A. Primary Data Sources - Surveys B. Primary Data Sources Stakeholder Interviews C. Secondary Data Sources Local Studies D. Publically Available National, State and Local data VI. Findings from Health and Community Data Socio-economic Indicators Health Indicators Priority I and Priority II Tables VII. Findings from the Community Input Process A. Health Needs B. Health Determinants C. Access Issues D. Special Populations E. Top Actions SJMAA Can Take to Impact Need VIII. Prioritization and Description of Needs Identified IX. Reflections on the Health Needs Assessment A. The Process: Lessons Learned & Recommendations for Future CHNA B. Strategic Next Steps Appendices A: Community Data B: Community Health Data C: Community Survey Questionnaire D: Interview Facilitator Guide E. Survey and Key Stakeholder Findings F. Community Survey Participants G: Local Studies Data Findings... 49

3 2015 Community Health Needs Assessment Executive Summary Compelled to Care for our Community As a faith-based health care organization in the Catholic Christian tradition, St. Joseph Mercy Ann Arbor s (SJMAA) work of providing services that benefit the community is core to our identity. While governed by laws and regulations for non-profit tax-exempt hospitals to provide services to those in need, we are ultimately compelled by a desire to extend the healing ministry of Jesus Christ (cf. John 13:14-17, Matthew 25:35-36). Our mission and core values call us to improve the health of our community with a particular concern for the poor and underserved. Assessing Community Health Needs SJMAA engaged in a robust Community Health Needs Assessment process. The CHNA process included an in-depth review of national, state and local data, key stakeholder interviews, community agency surveys and reviews of local level surveys and studies. The Community Benefit Ministry Council (CBMC) for SJMAA and Saint Joseph Mercy Livingston (SJML) reviewed information from each of these sources over a period of several meetings during the last quarter of 2014 and first quarter of The purpose of these meetings was to evaluate trends, needs, special populations and hospital and community capabilities. The CBMC also did a retrospective review of the 2012 Community Health Needs Assessment at this time. Health Challenges: Continued Disparities in Health Washtenaw County s population of 358,081 continues to increase, with Washtenaw being the second fastest growing county in SE Michigan only behind Livingston County. Although Washtenaw County has a very low unemployment rate (4.1% in October 2014), and a smaller percentage of residents below poverty when compared with Michigan, Washtenaw County also has several economically disadvantaged communities within its borders; in many of these same communities, more than 20% of the population do not have a high school diploma. Great disparities exist among between communities in health status and mortality despite improvements in insurance coverage. Much of the difference can be attributed to social determinants of health and differences in healthy behaviors, literacy and access. Health Care Priorities The CHNA identified 15 health needs for Washtenaw County. Of these, the Community Benefit Ministry Council (CBMC) and Executive Leadership Team classified two (2) as high priority based on size and severity of the problem, the health system s ability to impact the problem, and the likelihood that efforts would make an impact. These two priorities are: Obesity Behavioral Health, which includes Mental Health and Substance Abuse Our Strategic Response The Community Benefit Ministry Council (CBMC) will manage SJMAA s response to the health needs identified in this CHNA. As a first step, SJMAA has worked with its experts to determine high level strategies for strategies for both priorities, Obesity and Behavioral Health. These experts have identified the following strategies to address these needs: i

4 Obesity: Improve the coordination of and support for existing community resources addressing this need Support schools with education & prevention strategies, nutrition and physical activity, and behavioral health Increase community access to nutritious foods Increase community opportunities for physical activity Increase education in community venues regarding health behaviors Behavioral Health: Improve the coordination of and support for existing community resources addressing this need Improve access to adolescent behavioral health Address access to care barriers such as transportation, ability to pay, awareness of insurance benefits, and the number of providers Increase education of and support for primary care to address behavioral health needs Improve access to substance abuse treatment and increase support for patient compliance Specific implementation plans, with tactics aligned to these strategies, will be developed, implemented and measured for effectiveness. These implementation plans will reviewed and updated regularly to ensure SJMAA is effective in its response to these identified health needs. ii

5 I. Introduction and Mission St. Joseph Mercy Ann Arbor (SJMAA) is one of six hospitals comprising Saint Joseph Mercy Health System. Saint Joseph Mercy Health System, itself a member of Trinity Health, is a health care organization serving six counties in southeast Michigan including Livingston, Macomb, Oakland, St. Clair, Washtenaw and Wayne. St. Joseph Mercy Hospital Ann Arbor is a 537-bed hospital primarily serving Washtenaw County in partnership with its many physicians and community services. As part of Trinity Health, SJMAA s mission is to serve together in the spirit of the Gospel to be a compassionate and transforming healing presence within our communities. SJMAA embraces the core values of Reverence, Commitment to Those Who are Poor, Justice, Stewardship, and Integrity. We are faithful to who we say we are. Our Mission guides everything we do. As Saint Joseph Mercy Health System continues our healing ministry into the 21st century, we are called to both serve others and transform care delivery. We reinvest our resources back into the community through new technologies, vital health services and access for everyone regardless of their circumstances. We are compelled to care for our community. As a faith-based health care organization in the Catholic Christian tradition, SJMAA s work of providing services that benefit the community is core to our identity. While governed by laws and regulations for non-profit tax-exempt hospitals to provide services to those in need, we are ultimately compelled by a desire to extend the healing ministry of Jesus Christ (cf. John 13:14-17, Matthew 25:35-36). Our mission and core values call us to improve the health of our community with a particular concern for the poor and underserved. We call our commitment our Community Benefit Ministry. Our Community Benefit Ministry is an organized and measured approach to meeting community health needs. It implies collaboration with a community to benefit its residents by improving health status and quality of life. 1

6 II. A Retrospective Review In 2012, St. Joseph Mercy Ann Arbor, participated in a Community Health Needs Assessment (CHNA) for the Washtenaw County area to identify community perceptions of health concerns, barriers to access, gaps in service, health education, prevention services, vulnerable populations and social concerns. At that time, a plan was developed for addressing needs within the community. The full report can be viewed at In that 2012 Needs Assessment, the health priorities listed in the table below were identified and plans were implemented to address each priority need. As part of the 2015 Community Health Needs Assessment process, a retrospective review of the 2012 CHNA and Implementation plan was conducted. This review included collecting information on each of the Community Benefits programs supported in FY2014 against the following metrics: Number of individuals served Alignment of the initiative with an identified need in the CHNA Included in the 2012 CHNA Implementation Plan Metrics for program impact Total expenditures on the program The complete inventory of community benefits is available on request and is provided annually to the IRS in compliance with the IRS requirements for charitable hospitals. SJMAA evaluated progress in impacting the needs it had prioritized in its 2012 CHNA. SJMAA had selected seven (7) health and social needs as priorities and identified many initiatives to address those needs in its 2012 Plan. The assessment of the change, if any, in the metrics related to those priorities is included in the table below. As can be seen, the data were mixed regarding the trend for most priorities. In some cases, this was because relevant, timely data of community-wide impact were not available at the community level, regardless of SJMAA s collection of measurable results for its specific initiatives. The community did experience greater-than-expected improvements in breastfeeding, and in adult immunization rates; SJMAA had clear, demonstrable programs related to these priorities PRIORITIES Obesity Immunizations Dental Health TREND Mixed Mixed- Favorable Mixed 2 DETAILS behind TREND The combined percentage of adults who are overweight or obese has declined since 2006, but the combined percentage of children ages 2-5 who are obese or overweight has risen since Immunization rates for adults are better in Washtenaw than Michigan overall and the number of hospitalizations and deaths in Washtenaw is lower than Michigan for related conditions. Washtenaw s trend for pneumonia and flu-related deaths is favorable. However, a higher number of Washtenaw students receive vaccine waivers than Michigan students overall. Data were not found regarding dental access. However, a few community interviews pointed toward financial access issues for underinsured and low income individuals.

7 2012 PRIORITIES Access to Care Mental Health Breastfeeding Mammograms TREND Unclear Poor Good Unclear DETAILS behind TREND Data regarding access to care pre-date Medicaid expansion so the trend is unclear. Community interviews and surveys indicate adequate access to primary care. Community interviews and surveys revealed several specialties for which access continues to be a problem for Medicaid and underinsured recipients. Data regarding mental health are poor; the percent of people reporting days of poor mental health grew most recently. Community interviews and surveys indicated a high need for increased access and capacity for mental health and behavioral health services for many sub-populations. The number of Washtenaw women attempting to breast feed has consistently risen since The trend for women who breastfeed at least 6 months was less clear over that same period. Overall, Washtenaw breastfeeding rates are higher than in Michigan. Mammogram utilization data are dated and therefore offer little insight. Washtenaw has historically had a higher breast cancer mortality rate than Michigan but the trend is favorable and Washtenaw s breast cancer age-adjusted death rate was lower than Michigan in 2012 (the most recent year available). 3

8 III. Summary Observations from the Current CHNA Service Area Saint Joseph Mercy Ann Arbor s service area is defined as all of Washtenaw County. It shares the western portion of Washtenaw County with Saint Joseph Mercy Chelsea. The total population of Washtenaw County was estimated to be 354,240 in 2013, with small increases annually. While the total population is growing, the population under age 18 has consistently declined over the past four years while the over-65 population has grown. Washtenaw County s population continues to be racially diverse. Assessing Community Health Care Needs SJMAA engaged in a robust Community Health Needs Assessment (CHNA) process. The CHNA process included an in-depth review of national, state and local data, key stakeholder interviews, community agency surveys and reviews of local level surveys and studies. The Community Benefit Ministry Council (CBMC) for SJMAA and Saint Joseph Mercy Livingston (SJML) reviewed information from each of these sources over a period of several meetings during the last quarter of 2014 and first quarter of The purpose of these meetings was to evaluate trends, needs, special populations and hospital and community capabilities. The 2015 Community Health Needs Assessment identified fifteen areas of potential need. A potential need was evidenced by a wide variance between local and regional metrics, an unfavorable trend, issues identified by a majority of survey respondents, issues identified by multiple, key stakeholders or issues identified by local, third-party studies. In total, the following issues were identified as potential needs to be addressed POTENTIAL NEEDS HEALTH CONDITIONS HEALTH BEHAVIORS ACCESS ISSUES HEALTH DETERMINANTS Breast Cancer Chronic Diseases: Diabetes and Liver Disease (priority) Obesity Asthma Alcohol abuse Immunizations Nutrition and healthy eating Hospital-based care Behavioral Health/ Mental Health Dental Health Specialist physicians End of life care Health Education and Awareness Transportation Health insurance enrollment 4

9 Health Care Priorities and Contributing Risk Factors Using the data, findings and feedback from its fact-finding process, the CBMC and SJMAA leadership prioritized the community s needs according to the four criterion of: The degree to which the need was essential to the overall health of the community The urgency of the need SJMAA s ability as a hospital to address the need The likelihood SJMAA s efforts would impact the need. These four criteria balance considerations of the depth and urgency of the needs, and the hospital s relative ability to affect the need based on its expertise, programs and partner relationships. As a result of this discernment process, SJMAA prioritized the following two health needs in its service area: 1. Overweight & Obesity (which underlies most Chronic Diseases) 2. Behavioral Health, which includes Mental Health and Substance Abuse Our Response To address needs identified in the CHNA, SJMAA will engage key internal and community partners in identifying and implementing evidence-based strategies. These strategies will guide SJMAA s existing community benefit programs and efforts, as well as new tactics and partnerships that can be integrated into its Community Benefit Ministry. 5

10 IV. Community Description The St. Joseph Mercy Hospital Ann Arbor (SJMAA) service area for purposes of this needs assessment is defined as the population of Washtenaw County. Washtenaw County is estimated to have a population of 358,081 as of December 2014 (SEMCOG). The population of Washtenaw County is growing. This most recent estimate shows population growth of nearly 2.6% between 2010 and This is up 9.2% from 324,372 in CY The population of Washtenaw County is also aging. The population under age 18 has consistently declined over the past four years while the over-65 population has grown. Washtenaw County s population is racially diverse with 76.5% White, 13.9% Black, 9.1% Asian, and 4% Native American in The charts below show how the age and mix of ethnicities has changed over time. DEMOGRAPHICS - AGE TOTAL POPULATION 345, , , ,240 % Under Age % years % years % 65+ years SOURCE: National Center for Health Statistics (NCHS) as prepared for Michigan Department of Community Health 6

11 DEMOGRAPHICS - RACE % White % Black % Native American % Asian/Pacific Islander SOURCE: National Center for Health Statistics (NCHS) as prepared for Michigan Department of Community Health In 2013, approximately 16.7% of Washtenaw households lived in poverty. This number has been relatively stable since The percent of households at the highest income levels has been increasing since Washtenaw County s unemployment has been lower than unemployment rates in Michigan during this time period. INCOME INDICATORS % Households Less than $35,000 per year % Households $35,000 - $74,999 per year % Households More than $75,000 per year % People Below Poverty Level % Children age <18 living in poverty % Households Lead by Single Woman with Children below Poverty % Population age 16+ unemployed, looking for work SOURCE: American Community Survey 1-year estimates. Washtenaw County has a high proportion of people with a 4-year degree or higher. However, Washtenaw County also has geographic pockets where more than 20% of the population has less than a high school diploma as shown in Map 2. EDUCATION INDICATORS % High School Graduates Graduating On Time % Pop age 25+ with 4-Year degree or higher SOURCE: American Community Survey and Michigan League for Public Policy-Kids Count survey. 7

12 Map: Less than High School Diploma. Washtenaw County includes three (3) acute care hospitals with comprehensive medical and surgical care programs open to the general public. Each facility accepts patients of all races, genders, ethnicities and a variety of insurance plans, including Medicaid and Medicare. The Veterans Affairs Hospital in Ann Arbor provides medical and surgical services to residents eligible for veterans benefits. WASHTENAW COUNTY HOSPITALS Medical/Surgical Beds Psychiatric Beds Forest Health Medical Center 68 0 St. Joseph Mercy Ann Arbor University of Michigan Hospitals St. Joseph Mercy Chelsea Veterans Affairs Hospital Ann Arbor Select Specialty Ann Arbor (LTACH)

13 V. Information Sources & Data Collection Approaches SJMAA engaged a market research company, Arbor Advisors, to lead the process of gathering both primary and secondary data. The process involved actively reaching out to community experts through surveys and interviews, delving into already-conducted local studies that used focus groups, community forums and surveys, and gathering of local, regional and nationally available data sources. A. Primary Data Sources - Surveys Arbor Advisors generated primary data through a survey of essential community agencies. A webbased community health needs survey was created in November 2014 to evaluate the health and social needs in the SJMAA service area. The survey was composed of eight questions regarding the top health concerns, barriers to health care services, gaps in health care services, vulnerable populations, and the impact of various social determinants of health. Survey participants were asked to identify organizations that are already being successful in addressing some of the needs. Survey participants were also given an opportunity to suggest ways they thought SJMAA could address some of the needs they had identified. Participant demographic information was collected, but on a voluntary basis with many participants opting to remain anonymous. The survey also allowed respondents to recommend other people to contact for information, and surveys or interview invitations were extended accordingly. The web-based survey was available to the public from November 2014 through January The survey was distributed to hand-selected individuals within community agencies and programs, as well as to SJMAA s key community outreach staff and staff working with vulnerable populations. The open survey was available for direct re-distribution by respondents and invitees; this was encouraged. invitations to complete the survey were sent two and three times during this period. B. Primary Data Sources Key Stakeholder Interviews During this same period of November 2014 through January 2015, interviews were conducted with key stakeholders. These stakeholders were identified as local subject matter experts, community leaders or experts within key populations such as the Latino population or for the elderly. The focus of these interviews closely aligned with the questioning on the survey regarding health care service needs and barriers, vulnerable populations, and social determinants of health. These intensive interviews offered great opportunity to explore issues of service coordination and partnering, and detailed assessment of specific population needs. C. Secondary Data Sources - Local studies Where available, local studies were used to inform the CHNA. These studies were made available by people who participated in this CHNA s interviews and surveys, or were suggested by these participants as resources for additional information. In each key stakeholder interview, the participant was asked whether his or her agency had conducted any studies that would be useful for this CHNA. The survey also gathered suggested information resources. Some studies were regional in nature, such as those conducted by the Area Agency on Aging. Regional studies provided insights into potential health needs and social determinants of health and were used to inform the direction of additional, local data research. Other studies were specific to Washtenaw County and did not exclusively measure health needs or determinants of health but did provide some data pertinent to this CHNA process. These latter studies typically focused on at-risk populations, such as economically disadvantaged youth, the elderly and minorities. This CHNA used the following studies: 9

14 Encuesta Buenos Vecinos (Casa Latina) - Community Survey At-Risk Youth: Data Portrait 2014 Washtenaw County Health Department Survey of Washtenaw County BluePrint for Aging Housing Affordability and Economic Equity- Analysis Washtenaw County Office of Community and Economic Development Building a Better Washtenaw Washtenaw Public Health Department - D. Publically Available National, State and Local data Local, state and national data on demographics, socio-economic factors, health behaviors, health status, access, and mortality were gathered from a wide range of sources. Some data were limited by the frequency by which it was collected and by the geographic level of detail. The most recent data were reviewed. Where possible, data were broken down to the lowest level of city or township with comparisons conducted between increasingly larger geographies. For example, where Ypsilanti Township data were available, they were compared with Washtenaw and Michigan overall. In most cases, local level (city) data were not available from these sources in a timely and meaningful (statistically relevant) manner; most data compared Washtenaw with Michigan overall. The interviews and local surveys were relied upon for the most local- information. Some of the following resources served as the basis for the National, State and Local data analysis: Michigan Office of Highway Safety Planning Michigan Profile for Healthy Youth (MIPHY) _64839_38684_29233_ ,00.html Michigan Behavioral Risk Factors Surveillance System (MI-BRFSS) American Community Survey Michigan League for Public Policy- Kids Count Bureau of Labor Statistics Washtenaw Alliance for Children and Youth Washtenaw County Health Department Southeastern Michigan Council of Governments Michigan Department of Community Health, Vital Statistics Pediatric Nutrition Surveillance Study 10

15 United Way of Washtenaw County 14UW%20ALICE%20Report_MI_Lowres_ pdf Michigan Department of Education studentinformation/graduationdropoutrate.aspx 11

16 VI. Findings from Health and Community Data Socio-Economic Indicators: INCOME Researchers have identified that educational attainment and poverty are two factors that can have significant influence when it comes to health. (Community Commons, CHNA.org). While most data were not available at the community level within Washtenaw County, data did show that those Washtenaw communities with lower average household income were more likely to have higher mortality rates, with the highest overall death rates in Ypsilanti (average household income $33,406) compared with Ann Arbor (average household income $55,003) DEATH RATES/1, WASHTENAW Ypsi Ypsi Twp Ann Arbor Pittsfield SOURCE: MDCH Vital Statistics This reflects similar findings by the Washtenaw County Health Department in its 2010 Health Improvement Plan Survey regarding the self-reported health status of residents based on income. Comparative Health Status of Adults in Washtenaw County by Income Income less than $35,000 per year County Average General health status (fair or poor) 28% 12% Days in month physical health not good (10 or more) 19% 13% Day is month mental health not good (10 or more) 31% 14% Activity limited due to physical/mental/emotional problem 27% 21% Overweight or obese (yes) 60% 59% SOURCE: Washtenaw County Health Department, Building a Healthier Washtenaw,

17 Income is also closely related to healthy behaviors. Washtenaw residents with lower incomes were less likely to engage in adequate physical activity and in eating nutritious foods, and they were more likely to smoke. Comparative Health Behaviors of Adults in Washtenaw County by Income Income less than $35,000 per year County Average Does not get adequate physical activity 55% 35% Eats less than five servings of fruits and vegetables per day 90% 82% Current smoker 12% 12% Adults in family reduced food intake due to cost in past year 13% 5% SOURCE: Washtenaw County Health Department, Building a Healthier Washtenaw, 2013 Socio-Economic Indicators: ACCESS TO NUTRITIOUS FOODS Although Washtenaw County has a lower percentage of food insecure residents than in Michigan overall, the total number of food insecure people has been rising. In 2013, over 44,000 Washtenaw residents accessed a food pantry for some of their nutritional needs. Of these, 2,829 were seniors and 9,717 were children. In 2014, seven percent (7%) of adults ages 60+ reported not having sufficient money to purchase foods. FOOD SECURITY WASHTENAW # Food Insecure People 47,890 44,850 46,850 48,660 N/A % Food Insecure People N/A % Children Eligible to Receive Free or Reduced Lunch # Any Accessing Food Pantries N/A N/A N/A N/A 44,500 # Seniors Accessing Food Pantries N/A N/A N/A N/A 2,829 # Children Accessing Food Pantries N/A N/A N/A N/A 9,717 # Food Insecure People 1,828,060 1,872,780 1,769,790 1,660,050 N/A MICHIGAN % Food Insecure People N/A % Children Eligible to Receive Free or Reduced Lunch SOURCES: USDA. Food Gatherers. BluePrint for Aging. Food Insecurity years: , , Percent of Adults eating five or more servings of fruits and vegetables per day Washtenaw overall 18% Earning Less than $35,000 yearly income 10% Less than high school education 12% Western Washtenaw County and other suburban and rural areas 9% SOURCE: Washtenaw County Health Department, Building a Healthier Washtenaw,

18 Socio-Economic Indicators: EMPLOYMENT Washtenaw County s unemployment rate historically has been lower compared to Michigan and is among the four counties including Ottawa, Kent, and Mackinaw with the lowest unemployment. EMPLOYMENT WASHTENAW % Population age 16+ unemployed, looking for work MICHIGAN % Population age 16+ unemployed, looking for work Socio-Economic Indicators: EDUCATION Overall, Washtenaw County has a high level of education attainment and a larger percentage of high school students graduating on time in comparison with Michigan. However, a study of economically disadvantaged students shows how low incomes closely correlate with an unfavorable probability of graduating from high school. These same communities with lower health status also were most likely to have lower overall education attainment levels. EDUCATION WASHTENAW % High School Graduates On Time % Pop age 25+ with 4-Year degree or higher % Economically Disadvantaged People Graduating HS N/A % High School Graduates On Time MICHIGAN % Pop age 25+ with 4-Year degree or higher N/A N/A SOURCE: Michigan League for Public Policy-Kids Count. SEMCOG/American Community Survey. Socio-Economic Indicators: HOUSING According to the National Low Income Housing Coalition (NLIHC), Washtenaw County has the highest housing wage of any county in the state, meaning the wage needed to maintain housing expenses below 30% of income. (NLIHC, 2014). Based on a recent study of housing affordability, the percent of Washtenaw households with housing costs that exceed 30% has grown substantially since UNAFFORDABLE HOUSING COSTS % Change Unaffordable Housing Costs (>30%) 11,397 23,835, 109 Very Unaffordable Housing Costs (>50%) 3,428 8, % Unaffordable 19% 29% % Very Unaffordable 6% 10% SOURCE: Housing Affordability and Economic Equity Analysis, Washtenaw Office of Community and Economic Development, 2015 Similarly, the United Way of Washtenaw County ALICE report, shows the number of households whose average income is insufficient to afford the basics of the housing, child care, food, health care, and transportation is poorest in these communities: 14

19 Community % Households in Poverty and Below ALICE Threshold Ypsilanti City 46% Ypsilanti Township 30% Salem Township 33% Northfield Township 32% Milan City 31% SOURCE: United Way Study of Financial Hardship Does not include York Township which includes the Federal prison. These high burdens of housing costs contribute, among other things, to the number of homeless individuals in Washtenaw County. In 2013, the Washtenaw County Office of Community and Economic Development estimated there were 4,413 individuals who received services to address homelessness. Of these 63% were single adults. Over 70% of the individuals receiving housing services were high school graduates, and 922 families accessed available services. Of the 690 chronically homeless individuals, 100% had a disabling condition such as serious mental illness or substance abuse disorders. Health Indicators: OVERALL Overall, Washtenaw County residents enjoy a favorable health status; Washtenaw County is sixth among Michigan s counties in overall health outcomes. On each of the key self-reported health status factors, Washtenaw compared favorably to Michigan. However, the percent of residents reporting days of fair or poor physical or mental health status in the past month has consistently risen since Nearly one-quarter of Washtenaw adults reported experiencing limitations due to a physical, mental or emotional problem in the most recent survey. Twenty-one percent (21%) of adults ages 60+ reported that pain kept them from participating in activities. OVERALL HEALTH STATUS ADULTS - SELF REPORTED WASHTENAW % Current Health Status as Fair or Poor % With at least 14 Days of Fair or Poor Physical Health in Past Month % With at least 14 Days of Fair or Poor Mental Health in Past Month % Limitations because of a Physical, Mental or Emotional Problem % Ages 60+ Where Pain kept them from participating in activities N/A N/A 21 % Current Health Status as Fair or Poor % With at least 14 Days of Fair or Poor Physical Health in Past Month MICHIGAN % With at least 14 Days of Fair or Poor Mental Health in Past Month % Limitations because of a Physical, Mental or Emotional Problem SOURCES: BRFSS Surveys. 60+ Survey of Washtenaw County

20 Health Indicators: PREVENTIVE BEHAVIORS Preventive behaviors include a wide range of actions residents can take to keep themselves healthy. Most data on health behaviors are collected through self-reporting on surveys. Overall, Washtenaw s adults are more likely to receive the influenza vaccination and Pneumonia vaccination than Michigan s adults. Unlike adults, though, Washtenaw s children are less likely to be fully vaccinated; 8.0% of Washtenaw s students have received vaccine waivers compared with Michigan s rate of 5.9%. Likewise, preventive behaviors can include screening tools, such as mammograms and colonoscopies. The data on mammograms show the percent of Washtenaw women receiving a mammogram is higher than the Michigan average, but these data are dated. Likewise, Washtenaw adults were more likely to have a screening colonoscopy or sigmoidoscopy than their Michigan peers. But the percent of Washtenaw adults reporting eating less than five (5) fruits and vegetables daily is lower than Michigan, and Washtenaw s rate is declining. PREVENTIVE CARE % Influenza (Flu) Shot in Past Year (Ages 65+) % Adults Ever Had Pneumonia Shot % Colonoscopy, Sigmoidoscopy (Ages 50+ and WASHTENAW Older, Appropriately Timed) N/A % Mammogram Ages N/A % Adults Eating <5 Fruits or Vegetables Daily * % Students with Vaccine Waivers N/A N/A 8.0 % Influenza (Flu) Shot in Past Year (Ages 65+) % Adults Ever Had Pneumonia Shot % Colonoscopy, Sigmoidoscopy (50 Years of MICHIGAN Age and Older, Appropriately Timed) N/A % Mammogram Ages N/A % Adults Eating <5 Fruits or Vegetables Daily % Students with Vaccine Waivers N/A N/A 5.9 SOURCE: BRFSS Surveys. Fruits and Vegetables: 2005, 2007, MDCH School Status Reports. Health Indicators: AMBULATORY-SENSITIVE CONDITIONS Washtenaw County generally has lower hospitalization rates for ambulatory-sensitive conditions. This implies residents are receiving necessary preventive and disease-management services. The one condition for which Washtenaw s hospitalization rate was higher was for asthma in children less than 18 years. The data for this metric were dated. Ambulatory Care Sensitive Hospitalization Rates per 10, Avg Asthma Hospitalizations - Ages < WASHTENAW MICHIGAN Asthma Hospitalizations All Ages All Ambulatory Sensitive Conditions - All Ages Asthma Hospitalizations - Ages < Asthma Hospitalizations All Ages All Ambulatory Sensitive Conditions - All Ages SOURCE: MDCH Hospitalization Rates: Washtenaw County Health Department average 16

21 Health Indicators: OBESITY Self-reported obesity rates in total have declined in Washtenaw County over the past several surveys for both adults and high school students. However, obesity continues to affect upwards of 60% of Washtenaw s population. Obesity rates in children ages 2-5, which are based on in-office measurements and not on self-reporting, have risen. During the most recent study on children ages 2-5, the percent of obese and overweight children in Washtenaw exceeded the rate for Michigan overall. OBESITY PERCENTS Adults Overweight (BMI ) Adults Obese (BMI 30.0 or Greater) WASHTENAW HS students who are obese (> 95th percentile for BMI by age and sex) N/A HS students who are overweight (between 85th and 95th percentile for BMI by age and sex) N/A Children ages 2 to 5 Overweight Children ages 2 to 5 Obese Overweight (BMI ) Obese (BMI 30.0 or Greater) MICHIGAN HS students who are overweight (between 85th and 95th percentile for BMI by age and sex) N/A N/A N/A HS students who are obese (> 95th percentile for BMI by age and sex) N/A N/A N/A Children ages 2 to 5 Overweight Children ages 2 to 5 Obese SOURCES: BRFSS, Pediatric Nutrition Surveillance Survey and Michigan Profiles for Health Youth Surveys. Student Data: , Child Data: , Health Indicators: SUBSTANCE USES The percent of Washtenaw adults and students who smoke tobacco is lower than Michigan overall and relatively stable. These data do not reflect any changes related to the increased use of e-cigarettes. The percent of Washtenaw high school students who reported smoking marijuana in the past 30 days (14.1%) is substantially higher than those who reported smoking tobacco (4.0%). The percent of adults and high school students consuming alcohol rose across every period measured, and the percent of Washtenaw adults reporting to be heavy drinkers is now higher than the Michigan average. The percent of Washtenaw high school students using heroin or pain killers without a physician prescription rose over both periods measured. WASHTENAW SUBSTANCE USE RATES % Adults Consuming >2 men /1 women drinks per day (Heavy) % Adults Consuming 5+ drinks per occasion previous month(binge) N/A % HS students who had at least one drink of alcohol during the past 30 days N/A % Adults Smoke Cigarettes Now, Every Day or Some Days % Adults Smoked, But Do Not Now % Adults Never Smoked % HS students who smoked cigarettes during the past 30 days N/A

22 WASHTENAW SUBSTANCE USE RATES % HS students who used marijuana during the past 30 days N/A % HS students who used heroin one or more times during the past 30 days N/A % HS students who took painkillers such as OxyContin, Codeine, Vidodin, or Percocet without a doctor s prescription past 30 days N/A SOURCES: BRFSS Survey and Michigan Profiles for Health Youth Surveys. Student Data: , Health Indicators: MORTALITY Measures of mortality are used to identify specific needs that might not otherwise be reflected in other data. Overall, Washtenaw enjoys favorable mortality rates compared with Michigan in every top causeof-death category. Washtenaw s age-adjusted death rates are mostly declining over time. In particular, Washtenaw s age-adjusted death rate for heart disease and pneumonia have improved substantially since However, Washtenaw s age-adjusted death rate for chronic liver disease and chronic lower respiratory diseases, which includes Chronic Obstructive Pulmonary Disease (COPD), has worsened over each of the past three years. MORTALITY WASHTENAW MICHIGAN Deaths / (ageadjusted) TREND Cancer GOOD Invasive Breast Cancer GOOD Chronic Liver Disease POOR Chronic Lower Respiratory Diseases POOR Diabetes N/A Heart Disease GOOD Pneumonia & Flu GOOD Cancer GOOD Invasive Breast Cancer GOOD Chronic Liver Disease POOR Chronic Lower Respiratory Diseases N/A Diabetes N/A Heart Disease GOOD Pneumonia & Flu N/A SOURCE: MDCH Vital Statistics. Chronic Liver Disease: , , , ,

23 PRIORITY I; PRIORITY II Tables Based on the findings of the community and health data, the following priorities were tentatively identified. These priorities are further refined based on the community input described in the following section, and the final prioritization of all these needs is discussed in Section VIII of this report. PRIORITY I Health Indicators PRIORITY II Health Indicators HEALTH CONDITIONS HEALTH BEHAVIORS ACCESS ISSUES Breast Cancer Chronic Diseases: Diabetes and Liver disease Obesity Asthma Alcohol abuse Immunizations Nutrition and healthy eating Hospital-based care Behavioral Health/ Mental Health Dental Health Specialist physicians End of life care Pain Management (Seniors) Chronic Diseases: High Blood Pressure and COPD Breast Feeding Mammograms Pregnancy and Pre-pregnancy care Nursing home care 19

24 VII. Findings from the Community Input Process A. Health Needs The key stakeholder interviews and community surveys created opportunities for community members to identify the determinants of health and health needs of the residents they serve. Where sample sizes were sufficiently large, the survey data was quantified by counting the frequency with which a metric was mentioned, or rankings of those metrics. Insights into the connectivity of needs, the specifics of needs and the significance of different needs often became most apparent in the qualitative portion of the data collection: open-ended responses and free-flowing interviews. While each participant identified needs specific to the residents his/her agency served, several common needs arose. Highest priority health issues chosen by 50% of more of respondents Obesity and Overweight Mental Health Poor Nutrition Substance Abuse, including prescription drugs Diabetes Alcohol Abuse Dental Health Nearly every interviewee noted the issue of obesity and overweight conditions, as well as the impact weight problems have on other issues such as chronic diseases, mental illness and overall nutrition. Obesity continues to be a priority for the Washtenaw County Health Department, and while it impacts some sub-populations more than others, obesity is considered to be non-discriminatory in that it is pervasive regardless of socio-economic, education or access-to-care factors. Mental Health also was mentioned by a majority of interviewees and survey respondents. Many suggested that due to the close connection between mental health and substance abuse, including prescription drug abuse, illegal drug abuse and alcohol abuse, these should be considered a single issue of Behavioral Health. Behavioral health issues were particularly noted for: Spanish-speaking populations requiring Spanish-speaking mental health specialists, including those who can prescribe, provide psychotherapies, and psycho-social supports. People with Mild to Moderate Mental Illness requiring greater access to care, follow-up care including drug monitoring and prescription renewals, and psycho-social supports Substance abuse treatment and case management options for all, including adolescents and adults, and particularly people with low incomes Lowest rated on the list of potential health issues were the health issues of: Cancer, End-of-Life Care, Heart Disease, Kidney Disease and Pregnancy Health. B. Health Determinants The community was asked to indicate the level of priority SJMAA should place on addressing several determinants of health. In the survey, participants were provided a list of 13 options, whereas they 20

25 were prompted with examples during the interviews. The interviews and surveys revealed the following as the community s highest priorities for SJMAA to address: Highest priority determinants of health in order by highest frequency of respondents Income/ Ability to Pay Preventive Health Behaviors such as breast feeding and exercise Education / Understanding of personal health needs Availability of Healthy Foods Social Norms and Attitudes While many interviewees acknowledged improvements in financial access related to the expansion of Medicaid, the inability to pay continues to negatively impact the community. For example, although Medicaid enrollment has expanded, Washtenaw County has few podiatrists or ophthalmologists who accept Medicaid. Additionally, Medicaid expansion does not benefit undocumented immigrants who do not qualify. High deductibles and co-pays continue to make the inability to pay a large barrier to seeking care. Preventive health behaviors and education/understanding of personal health needs were also highly rated as areas for SJMAA to address. These two determinants are closely linked, as it requires some understanding about what good health requires before recognizing the need to engage in healthy behaviors such as exercise. The community s concern with the availability of healthy foods was compatible with the earlier concern with poor nutrition and healthy behaviors. While there are many very good resources for healthy foods, and many agencies focused on this issue, there were concerns that low income households have difficulty accessing healthy food options on a regular basis. For example, the Milan food pantry manager noted that she cannot stock as much fresh produce as she or her recipients would like because she lacks refrigerator space. Finally, while it was not clearly indicated by the surveys, the interviews revealed transportation to be a barrier to accessing care and engaging in healthy behaviors. Interview participants noted that transportation is particularly difficult for low income individuals, and those who require multiple visits for care, such as for chemotherapy or chronic disease management. SOCIO-ECONOMIC FACTORS Health Education and Awareness Health insurance enrollment Transportation SPECIFIC NEED Culturally-sensitive education and awareness for immigrant and non-english speaking persons regarding navigation of health resources Low income, uninsured and undocumented people Low income and uninsured People with complex, chronic diseases that require multiple visits C. Access Issues Survey respondents and interview participants were asked about specific concerns they had regarding access to care. In the survey, they were provided a list of 12 types of care, whereas they were prompted with examples during the interviews. 21

26 Top access concerns in order by percent of survey respondents who favored Hospital Care Immunizations End-of-Life Nursing Home Specialty Care (e.g. cancer screening in elderly) Unfortunately, the community survey did not prompt for details when a respondent marked an access issue except for when a respondent marked Specialty care or in-home care. Therefore, the particular difficulties accessing hospital care could only be derived from interviews. The few interviews that mentioned this as a concern pointed to underinsurance and lack of insurance as one reason people are not getting hospital-based care such as outpatient surgery. D. Special Populations Survey and interview participants were asked whether there specific populations that do not have access to care. Because the respondents represent a wide range of agencies serving different populations, the responses varied significantly. The list of underserved populations and their specific needs appears in the table below. SPECIAL POPULATION Spanish-speakers Low income Immigrants with authorization and without authorization Caregivers Elderly Mild to Moderate Mentally Ill New Mothers Substance Abuse Homeless SPECIFIC NEED Social supports, Spanish-language services, Mental health specialists, especially ones that speak Spanish. This includes prescribing, psychotherapies, other treatment options, and social support. Access to mental health, Nutrition both in terms of food and education, transportation assistance $ or otherwise for health problems that require regular trips to the hospital Social supports, Spanish-language services Respite care for the caregiver or just knowledge of how to get assistance for relief for caregivers to go shopping, or get out of the house for appointments if there is not family or friends to stay with the family member. Caring for spouse, medication management Access to care and in community care management Mentors to continue breast feeding Access to care, case management and more options for different insurances Access to case management and support services, particularly for mental illness, substance abuse and prescription management. 22

27 E. Top Actions SJMAA Can Take to Impact Need The community was asked for suggestions regarding how SJMAA can best help to address the needs and determinants of health. While the suggestions were wide-ranging with some very specific and many generalized, overall the interviewees and survey participants suggestions fell into the following categories: COLLABORATE Nearly every participant highly valued collaboration with existing community partners as a key strategy for addressing the needs. It was oft-repeated that a lack of coordination created many of the barriers to access, and that many efforts were being duplicated across the community. Additionally, nearly every interviewee welcomed the opportunity to work more closely with SJMAA as it completes its CHNA and moves toward identifying its implementation plan. Most participants believed collaboration was essential to impacting the community s needs. INCREASE EDUCATION/AWARENESS Many community participants believed SJMAA can be a leader in providing health education in the Washtenaw community. The suggestions for this included providing more education in the community and at home, offering workshops and speakers, and helping people become more aware of resources that are available in the community. The Washtenaw County Health Department expanded this concept further by asking SJMAA to educate patients about immunizations and to better record immunizations it or its physicians provide for adults. IMPROVE CARE CAPACITY Because it is a healthcare provider, many respondents looked to SJMAA to play an active role in addressing the lack of capacity for some health services. This was particularly true for mental health and substance abuse. As one survey participant said: It doesn't seem there are enough providers to meet the needs of the full population needing mental health services at no or low-cost. ADDRESS BARRIERS TO ACCESS Many respondents noted barriers to care they believe SJMAA is well-positioned to address. Many suggestions focused on SJMAA s ability to assist people in enrolling in insurance programs or payment programs to reduce barriers related to the ability to pay. Other interviewees and respondents noted the importance of reducing social barriers such as English as a second language, cultural barriers to accessing care and simply the difficulties in navigating the care system. 23

28 VIII. Prioritization and Description of Needs Identified The body of community health needs data was refined to fifteen (15) health needs and determinants of highest importance. These 15 needs were chosen based on the presence of an unfavorable trend, a wide degree of variance from comparison geographies and/or if it was considered high priority to survey and interview participants. These 15 potential areas of focus, and the particular targets of the need for each are listed in the table below. ANN ARBOR HEALTH CONDITIONS HEALTH BEHAVIORS ACCESS ISSUES NEED Breast Cancer Chronic Diseases: Diabetes (priority) Liver disease (priority) Obesity Asthma Alcohol abuse Immunizations Nutrition and healthy eating Hospital-based care Behavioral Health/ Mental Health Dental Health Specialist physicians End of life care SPECIFIC TARGET Education, mammogram utilization and access to low cost treatment Chronic disease self-management education and nutrition education Access to low cost medical management Especially in lower income, lower education communities Adults - prevention, education and treatment Children/Teens - prevention, education and treatment Children prevention and education Teen prevention, education and treatment Adult Heavy Drinking and Binge Drinking education, prevention and treatment Adults - Immunizations Children - Immunizations Access to healthy foods, particularly for elderly, children, low income Education regarding good nutrition and food preparation options Access to hospital-based services such as outpatient surgery, imaging and lab for low income people and uninsured Care coordination and continuity with community partners to assure follow up Increased capacity and access for all populations, particularly outpatient services for: Low income/underinsured/ poorly insured, Homeless, Non-English speakers People with mild/moderate mental illness who need disease management Substance abuse treatment professionals Access for Low income/underinsured/ poorly insured Access for low income, uninsured and non-english speaking populations. Includes Ophthalmology, Podiatry. Respite care services and information HEALTH DETERMINANTS Health Education and Awareness Transportation Health insurance enrollment Culturally-sensitive education and awareness for immigrant and non-english speaking persons regarding navigation of health resources Low income and uninsured People with complex, chronic diseases that require multiple visits Low income, uninsured and undocumented people 24

29 Members of the SJMAA Community Benefit Ministry Council and SJMAA Executive Leadership team reviewed data related to these 15 needs. They were asked to rate each need independently in consideration of the following factors: Degree to which the need is essential to the community s overall health Urgency in addressing the need Hospital's unique ability to address the need Likelihood that the hospital s effort will make an impact on the need The chart on the follow page shows the relative ratings of each need based on the feedback of the CBMC and the Executive Leadership Teams. Bubbles that appear closer to the top-right were those for which the team felt SJMAA was more uniquely positioned to address the need and that the hospital s efforts would have an impact. The larger circles reflect needs that were considered more essential to the community s overall health. A blue circle represents a more-urgent need, while an orange circle represents a need that was rated to be less urgent. The CMBC spent a session reviewing this chart and its information to discern the needs that would be given highest priority. This discussion included careful consideration of the symbiotic relationships of many of the needs and the ability to potentially impact more than one need by focusing on specific populations and/or needs. As a result of this discernment process, SJMAA prioritized the following two health needs in its service area: 1. Overweight & Obesity (which underlies most Chronic Diseases) 2. Behavioral Health, which includes Mental Health and Substance Abuse These needs were selected based on the relative urgency of the need (blue bubble), the essential nature of the need to the overall health of the community (size of bubble), and that by addressing these particular issues, SJMAA might positively impact related needs. For example, in addressing Obesity, SJMAA might improve the percentage of people eating healthfully and reduce the prevalence of some chronic diseases such as diabetes. Likewise, in addressing Behavioral and Mental Health, SJMAA may positively impact alcohol abuse and reduce the need for hospital admissions. 25

30 Increasing bubble size indicates increasing degree of importance to community s overall health; larger bubbles are more essential to the community s overall health. Blue Urgent Need Green Moderately Urgent Need Orange Less Urgent Need 26

31 IX. Reflections on the Health Needs Assessment A. The Process: Lessons Learned & Recommendations for Future CHNA SJMAA is continuously improving its processes and this CHNA is no exception. There are boundless sources of information available to inform the CHNA process. Unfortunately, these data are often too dated to be of value, especially when measuring impact of programs. For example, the data regarding health insurance coverage had not yet caught up with the impact of the Affordable Care Act and Michigan s Medicaid expansion. It was difficult to ascertain the actual shift, if any, in health insurance coverage. Likewise, SJMAA knows that there are large variations in health access, prevention and literacy in Washtenaw. This is somewhat evidenced by mortality rates within communities such as Ypsilanti and Ypsilanti Township. However, data regarding the precursors to those deaths are less available, leaving SJMAA to rely on anecdotal information and its own internal, yet-incomplete data about these communities. A more robust process that engages multiple community partners to share efforts and costs to collect shared, community-specific data would be invaluable. These same agencies all require similar data for purposes of their own community assessments. The synergies and need to coordinate are clearly evident. In part because the data are boundless, and because health needs and the social determinants for health are similarly boundless, time becomes a rate limiting factor in sifting through to find meaningful sources of data and information. The entire CHNA process, to be comprehensive, requires a substantial amount of time and effort. Due to timing and other issues, a survey of community residents was not created, and hence the community voice was only heard through the agencies who serve them. Similar to the suggestion above, more time and a coordinated effort between multiple community agencies to collect data directly from residents would substantially improve the process. B. Strategic Next Steps By identifying Obesity and Behavioral Health as its top two priorities above many possible needs, SJMAA has created a clear call-to-action to focus the future work of its Community Benefit Ministry programs. SJMAA s implementation plan will identify the strategies and tactics it believes best suited to address Obesity and Behavioral Health. Equally important, the Implementation plan will include carefully considered metrics for evaluating the effectiveness of its Community Benefit programs in addressing these important priorities. As a first step in its implementation planning process, SJMAA has begun working with its experts to determine high level strategies for the priorities of Obesity and Behavioral Health. These experts have identified the following strategies to address these needs: Obesity: Improve the coordination of and support for existing community resources addressing this need Support schools with education & prevention strategies, nutrition and physical activity, and behavioral health Increase community access to nutritious foods Increase community opportunities for physical activity Increase education in community venues regarding health behaviors 27

32 Behavioral Health: Improve the coordination of and support for existing community resources addressing this need Improve access to adolescent behavioral health services Address access to care barriers such as transportation, ability to pay, awareness of insurance benefits, and the number of providers Increase education of and support for primary care to address behavioral health needs Improve access to substance abuse treatment and increase support for patient compliance Specific implementation plans with tactics aligned to these strategies will be developed, implemented and measured for effectiveness in collaboration with appropriate internal and external partners. SJMAA eagerly anticipates working in collaboration with Washtenaw County Health Department, The University of Michigan Medical Center, St. Joseph Mercy Chelsea and other community partners to expand the efforts of the CHNA by creating a unified community needs assessment in This effort in 2016 will improve the coordination and effectiveness of resources to address the full needs of Washtenaw County. 28

33 APPENDIX A COMMUNITY DATA For all appendices tables, red color is used to indicate a metric that is worse than the Michigan average. Blank cells indicate metrics for which data were not available. A trend indication is only provided when the most recent three years show a consistent trend; trends are not available if a metric only had two measurement periods. INCOME TREND % Population age 16+ unemployed, looking for work GOOD % People Below Poverty Level WASHTENAW % Children age <18 living in poverty % HH Lead by Single Woman with Children below Poverty % Households Below ALICE 39.0 % Population age 16+ unemployed, looking for work GOOD % Below Poverty Level GOOD MICHIGAN % Children age <18 living in poverty GOOD % HH Lead by Single Woman with Children below Poverty % Households Below ALICE 40.0 Food Insecurity: , , ALICE: Asset Limited, Income Constrained, Employed (United Way) 29

34 APPENDIX A COMMUNITY DATA 30