Document Butte_doc_eb1590eba3

2011 COMMUNITY NEEDS ASSESSMENT SILVER BOW COU NTY HEALTH DEPARTMENT Silver Bow County, Montana ---PAGE BREAK--- CONTACT INFORMATION Terri Hocking, Director Silver Bow County Public Health Department 25 West Front Street Butte, Montana 59701 Phone: [PHONE REDACTED] Email: [EMAIL REDACTED] Linda McGillen, Director of Public Relations and Marketing St. James Healthcare 400 S. Clark Street Butte, Montana 59701 Phone: [PHONE REDACTED] Email: [EMAIL REDACTED] 2011 COMMUNITY NEEDS ASSESSMENT ---PAGE BREAK--- ACKNOWLEDGEMENTS In the spring of 2010, the Butte-Silver Bow County Public Health Department embarked upon a thorough community health assessment to help inform local public health policy and priorities into the future. The assessment was intended to serve as a tool for determining ways in which lives can be improved for citizens of Silver Bow County through prevention programming and collaborative initiatives. The information contained in this document will serve as a foundation for a Community Health Improvement Plan (CHIP) and will ultimately help direct important public resources to areas of greatest need. The assessment was the result of county level data analysis as well as the expertise, wisdom and valued knowledge of numerous community members and organizations. The broad participation that occurred throughout the process, and will continue through completion of the CHIP, was necessary to make this assessment truly representative of the important issues facing Butte-Silver Bow County. The work could not have been done without a strong partnership between St. James Healthcare and the Butte-Silver Bow Public Health Department who are both financial contributors to the project. The process involved broad participation from citizens, local government and organizations. A debt of gratitude is owed to members of the project Steering Committee and community task force that gave valuable and scarce time to make this study a reality. Participants included the following organizations and individuals. STEERING COMMITTEE MEMBERS: Terri Hocking Butte-Silver Bow Health Department Linda McGillen Saint James Healthcare Jamie Paul Butte-Silver Bow Health Department Karen Billson Butte-Silver Bow Health Department COMMUNITY STAKEHOLDERS, TASK FORCE MEMBERS: Adult Protective Services Bridget Parker, Lindy Ballard Area V Council on Aging Mary Fleming Belmont Senior Center Ann Ueland Big Brothers Big Sisters Debbie Hall Butte CARES Pat Prendergast, John Jacobson Butte Food Bank Joann Cortese, Cathy Griffith Butte Rescue Mission Gwen Uphra, Rachel Freeman ---PAGE BREAK--- Butte Sheltered Workshop Mary Jo Mahoney Community Development Department Karen Byrnes Butte-Silver Bow Health Department Terri Hocking, Jamie Paul, Karen Billson, Karen Maloughney Dan Powers, Eric Hassler, Dan Haffey, Gail Caron Butte-Silver Bow Law Enforcement Sheriff John Walsh, Captain George Skuletich Butte School District #1 Dr. Linda Reksten Career Futures Kathy Quinn, Lynn Clark Community Counseling and Corrections, Inc. Steve McArthur Community Health Center Cindy Stergar, Michelle Miller, Megan Silzly, Nancy Jamiolkowski, Shawna Stepp, Jessica Hoff, Sandi Hickey, Leslie McCartney, Leah Francisco Department of Family Services Rhonda Belgarde, Jennifer Hoerauf Early Head Start Christina Barto Habitat for Humanity/NAHN Anna Lee Highlands Hospice Karen Sullivan Human Resources Council Elissa Mitchell, Barbara Brophy (Head Start) Linda Lowney (Youth Services) Montana Orthopedics Larry Curran Montana Tech Marilyn Cameron, Ahsley Makowski North American Indian Alliance Patty Boggs Public Housing Authority Revonda Stordahl, Clarissa Hogart Retired Senior Volunteer Program Michele Brennick Rocky Mountain Clinic Tom Ringo Rocky Mountain Hospice Kim Merritt Safe Space Venna Walker St. James Healthcare Kevin Dennehy, Linda McGillen, Paula McGarvey United Way Kathleen McNamee, Dustin Woodards Western Montana Mental Health Kathy Dunks ---PAGE BREAK--- TABLE OF CONTENTS CHAPTER ONE: INDICATORS OF PUBLIC HEALTH Pages 1-1 – 1-38 Introduction Page 1-1 Methodology Page 1-1 Key Findings Page 1-2 I. Population and Demographic Factors 1.0 Population Trends 2.0 Density and Distribution 3.0 Shifting Population 4.0 Characteristics of the Population 4.1 Age 4.2 Gender 4.3 Race/Ethnicity 4.4 Households 4.5 Educational Attainment 5.0 Population Projections Page 1-5 Page 1-5 Page 1-5 Page 1-6 Page 1-7 Page 1-7 Page 1-8 Page 1-8 Page 1-9 Page 1-9 Page 1-10 II. Socioeconomic and Housing Factors 1.0 Median Household Income 2.0 Poverty 3.0 Housing 3.1 Age and Condition 3.2 Senior Housing 3.3 Neighborhoods Page 1-14 Page 1-14 Page 1-15 Page 1-16 Page 1-16 Page 1-18 Page 1-19 III. Social Behavioral Factors 1.0 Crime 2.0 Child Well-being 3.0 Substance Abuse and Driving 4.0 Homelessness Page 1-21 Page 1-21 Page 1-21 Page 1-24 Page 1-26 IV. Environmental Factors 1.0 Air Quality 2.0 Food and Consumer Safety 3.0 Waste Water 4.0 Superfund-related Factors Page 1-28 Page 1-28 Page 1-29 Page 1-29 Page 1-30 ---PAGE BREAK--- V. Health Indicators 1.0 Overview 2.0 Data Table-Key Indicators of Health 3.0 Mental Health Page 1-32 Page 1-32 Page 1-35 Page 1-38 CHAPTER TWO: ANALYSIS OF GAPS IN PROGRAMS & SERVICES Pages 2-1 – 2-25 Introduction Page 2-1 1.0 Key Population Factor 1.1 Services for Senior Citizens Page 2-2 Page 2-2 2.0 Key Socioeconomic Factors 2.1 Services to Address Poverty and Low-Income Needs 2.2 Services to Address Housing, High-poverty Neighborhoods and Decay 2.3 Services to Address Homelessness Page 2-6 Page 2-6 Page 2-9 Page 2-11 3.0 Key Factors Related to the Physical Environment 3.1 Programs to Address Air, Water and Soil Quality and Food Safety Page 2-12 Page 2-12 4.0 Key Social and Behavioral Factors 4.1 Programs to Address Crime 4.2 Programs to Address Child Well-being 4.3 Programs to Address Substance Abuse Page 2-14 Page 2-14 Page 2-15 Page 2-17 5.0 Key Health Factors 5.1 Services to Address General Health 5.2 Services to Address Mental Health 5.3 Services to Address Oral Health Page 2-19 Page 2-19 Page 2-22 Page 2-24 NEXT STEPS Page 3-1 ---PAGE BREAK--- CHAPTER ONE INDICATORS OF PUBLIC HEALTH ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐1 I P a g e INTRODUCTION This section of the Silver Bow County Community Needs Assessment examines indicators of public health to help inform a community planning process. It provides an examination of population-level issues including demographic, socioeconomic, environmental, behavioral and general health factors. The relationship between these components of public health point to a social imperative—that public health practitioners, social service providers, and medical providers work in the most collaborative way possible to create a healthier environment for the county’s citizens. Information contained in this section also respects the link between land use and public health, recognizing the importance of community design to health of citizens. As such, the document draws from the Butte-Silver Bow County Growth Policy, particularly in the analysis of population and housing, and demonstrates the necessary collaboration between public health officials and county planners. METHODOLOGY Data contained in this section draws from community assessments that have been completed in recent years including the following documents or data bases:  Butte-Silver Bow County Growth Policy; 2008 Update,  Butte-Silver Bow County Housing Plan; 2006  Butte Community Health Center; Community Needs Assessment; 2009,  Butte-Silver Bow County DUI Court Application to the Montana Department of Transportation 2010; Needs Assessment  Butte-Silver Bow Environmental Health Assessment; 2006,  Human Resources Council, District XII; Community Needs Assessment; 2009,  Centers for Disease Control, Behavioral Risk Factor Surveillance System (City and County Data); 2008,  Montana Prevention Needs Assessment Survey Results for 2008; Silver Bow County, and  Western Montana Mental Health Center CDBG Grant; Needs Assessment; 2006. In addition, the most recent available Census data was used to update data where such an update helped to inform the public health discussion. A set of meetings with stakeholders in the County also contributed to the analysis of needs and gaps in services. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐2 I P a g e KEY FINDINGS Population Findings  Butte-Silver Bow County has experienced a net decline in population since the 2000 decennial census. In order to reach the 2000 population level, the county would need an increase of over 1,600 people.  Population growth would have to occur through in-migration because the birth rate is relatively low and the number of people in child-bearing years is disproportionately low.  Median age is increasing over time; at 41.6, it is up 2.7 years from 2000 and is higher than both the state (39.3) and the nation (36.7)  Senior citizens comprise 16.5% of the population and are projected to comprise 25% of the population by 2025; the number of seniors is projected to reach nearly 8,933, an increase of over 3,000.  Although Butte-Silver Bow County’s population has not grown over the last twenty years, it has shifted away from the urban core to low density areas on the periphery of the urban core; more people are living farther away from job centers, amenities and services, creating more travel distances, emissions and more potential for crashes. Socioeconomic and Housing Findings  Butte-Silver Bow County’s income distribution is more heavily weighted toward the lower income cohorts; Median Household Income at $37,346 is a mere 71.6% of the national figure ($52,175).  Butte-Silver Bow County’s poverty rate has been on the rise going from 14.9% in 2000 to 15.8% in 2009  There are high concentrations of poverty in pockets of the county, particularly in parts of Census Tract One and Two in the older town site, and Tract 6; Tracts one and two contain over half of the county’s population living below the federal poverty line.  37% of the population is at or below 200% of the federal poverty line; 15% of the population has health care costs covered by Medicaid.  Butte-Silver Bow County has a significant number of housing units in unsound to fair condition (over 3,500 or 28% of housing stock); three quarters of the substandard housing units are located in Census Tracts One and Two in the older town site.  As the number of people 65 years of age and older grows, the need for home modifications, healthcare and other supportive services to help older Americans live safely and comfortably in their homes is also growing. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐3 I P a g e  High poverty neighborhoods, particularly in Census Tract One of Silver Bow County, where two of the highest poverty Block Groups in the county are located, are contributing to the perpetuation of intergenerational poverty. Environmental Findings  Air Quality:  The majority of air quality concerns in Butte-Silver Bow are the result of small particulate matter (PM) being released into the ambient (outside) air; although not currently in violation of air quality standards for PM, the County is very close to violating PM-2.5 standards (particulate matter 2.5 microns in size or less). Control measures are being developed.  Air quality is impacted by the phenomenon of population shifting from the urban cluster to peripheral areas, which has caused an increase in travel times to work and service centers and results in more auto emissions.  Superfund Related Factors:  The Butte area and Clark Fork River Basin together comprise the largest Superfund site in the United States.  Contaminants of concern (COC’s) identified by the EPA include lead, arsenic, and mercury.  The County has implemented a number of programs to address surface water, soil contamination and attic dust in homes.  To date, the following contaminated-related abatements have been completed:  396 yard abatements have been completed  118 attic dust abatements have been completed  32 interior dust cleanings have been done  149 lead-based paint abatements have been completed Social Findings  Butte-Silver Bow County has the highest crime rate among Montana’s major counties for the seven index crimes (homicide, rape, robbery, aggravated assault, burglary, larceny and motor vehicle theft)  Butte-Silver Bow has a set of social factors that present a high risk for unhealthy child development including a high crime rate, high rate of domestic violence, norms favorable toward substance abuse, a high rate of poverty and high poverty neighborhoods  The occurrence of Severe Emotional Disturbance in children between the ages of 9 and 17 is significantly higher in Butte-Silver Bow than the national rate ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐4 I P a g e  Nearly 30% of tenth grade students and just under half of high school seniors indicated they had engaged in binge drinking within two weeks of the 2008 Prevention Needs Assessment Survey  By twelfth grade, over 60% of students in 2008 were at high risk for problem behaviors  Drinking and driving poses a threat to public health in the County; the 2008 rate of DUI crimes per 100,000 people was up 135% over the 2004 rate; the local 2008 DUI crime rate per 100,000 people was nearly 20% higher than the rate for Montana overall General Health Findings  In the 2008 Behavioral Risk Factor Surveillance System report, Butte-Silver Bow County ranked particularly high in the percentage of adults that:  Have had all teeth extracted (7/177)  Have had any permanent teeth extracted (6/177)  Are overweight (2/177)  Are current smokers (6/177)  Smoke everyday (11/177)  Have been told have coronary heart disease (9/177)  According to the Montana Department of Health and Human Services 2009 County Health Profile,  The leading cause of death in Butte-Silver Bow County is heart disease; the associated county death rate of 256.8 per 100,000 population far exceeds the state death rate of 198.3 per 100,000 population  The suicide rate at 27.5 per 100,000 population exceeds the state rate of 20.3 per 100,000; (Montana consistently ranks in the top five states in the nation with regard to the suicide rate)  The percent of mothers who smoke during pregnancy is significantly higher than the state— 28% compared with 18%  The unintentional injury death rate (non-motor vehicle) far exceeds the state rate—84.3 per 100,000 population compared with 61 per 100,000  Between 1997 and 2006, the number of people served by the Western Montana Mental Health Center in Butte increased by 162%; the number served there indicates the rate of mental illness is approximately 4.3% of the population1. 1 Western Montana Mental Health Center, 2006 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐5 I P a g e I. POPULATION AND DEMOGRAPHIC FACTORS 1.0 Population Trends Population and demographic trends in Butte- Silver Bow have historically been linked to economic cycles of the mining industry. From the discovery of precious metals during the late 19th century until 1920, the population of Silver Bow County saw rapid growth. After peaking at just over 60,000 in 1920, according to historical population data provided by the U.S. Census Bureau, the population began a long period of decline, bottoming out at 33,941 in 1990. For the first time since 1920, the decade between 1990 and 2000 showed a slight increase in population While, Census population estimates for the early part of new millennium have shown Butte-Silver Bow returning to a trend of decline, more recent figures point to slight growth. The 2009 Census estimate places the population at 32,949, an increase of 359 people since 2007. However, in order to surpass the 2000 decennial census figure, the county will need to show a gain of more than 1,657 people. 2.0 Density and Distribution Butte-Silver Bow County covers an area of 718.31 square miles and includes 48.2 people per square mile. Approximately 88% (30,509) of the county’s population resides within the urban cluster2 while approximately 12% (4,097) of the population resides in areas outside the urban area3. (Refer to Figure 5 for illustration of the urban cluster.) 2 A 2000 Census term describing a densely settled territory that has at least 2,500 people but fewer than 50,000. 3 US Census Bureau; Census of Population and Housing, 2000 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Butte City Silver Bow County Figure 1 Long‐term Population Trend Butte and Silver Bow County City‐county consolidation 34,606 33,717 33,351 33,052 32,869 32,737 32,646 32,590 32,776 32,949 31,500 32,000 32,500 33,000 33,500 34,000 34,500 35,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Figure 2 Recent Population Trends Butte‐Silver Bow County ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐6 I P a g e Nearly 33% (9,990 people) of the county’s urban population is concentrated in Census Tracts 1 and 2 which are north and west of Front Street. Thirty-seven percent (11,350 people) of the population within the urban limits is contained in Census Tracts 3, 4 and 5— the area south of Front Street and bordered by Continental Drive to the east and Interstate 90 to the south and west. The remaining 30% (9,169 people) are concentrated in Tracts 6, 7 and 8—the area south of Interstate 90.4 3.0 Shifting Population U.S. Census Bureau figures from 1990 and 2000 indicate that Butte-Silver Bow County experienced an internal redistribution of population. Redistribution is indicated by population decline of up to 8.3% in five of the county’s Census Tracts simultaneous with population gains as high as 29.2% in three Census Tracts. Significant gains and losses internally occurred in the context of only 1.95% growth in county population during the same period. (Refer to Figure Census Tracts 1 through 5 showed losses ranging from 0.9% to 8.3%. The areas of loss generally occurred within the older neighborhoods within the urban limits in the following specific areas:  North side or Kennedy Elementary School area  West Elementary School area  Emerson Elementary School area  Whittier Elementary School area  Old Greeley School area 4 Based on US Census Bureau Data by Census Block Group; Census of Population and Housing, 2000 Figure 4 Urban Cluster 30,509 4,097 Figure 3 Urban v. Rural Population Butte‐Silver Bow County Urban Rural 0 2000 4000 6000 Tract 8 Tract 7 Tract 6 Tract 5 Tract 4 Tract 3 Tract 2 Tract 1 1990 2000 Figure 4 Change in Population by Census Tract Butte‐Silver Bow County Figure 5 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐7 I P a g e While there were pockets of growth inside the urban limits of Silver Bow County, areas of growth during the period occurred primarily on the periphery or outside the urban limits to the north, east and south and in Census Tracts 6, 7 and 8. These Tracts showed gains of between 1.4% and 29.2% between 1990 and 2000. Tract 8, the majority of which exists outside the urban limits, experienced the highest growth during period at 29.2%. Growth style in these areas is low-density single family units. Notable areas of growth within the Tracts included:  Beef Trail/Little Basin Creek area  Black Tail Loop area  Bull Run area  Hillcrest Elementary School area (Country Club-Holly Lane areas)  East Ridge area  Hanson Road (new YMCA, Old Stockyards area)  Moulton Reservoir area 4.0 Characteristics of the Population 4.1 Age The median age of the Butte-Silver Bow population is increasing over time. At 38.9, the median age in 2000 was higher than both the state (37.5) and the nation (35.3) and has been on the rise since 1980 when it was 32.1.This can be attributed to the changing distribution of age groups in the county. The age cohort ‘65 years of age and older’ comprises the largest age group in the county, as it did during the entire study period—1980 to 2000. According to the 2000 Census, seniors comprised 16% (5,499) of the county population compared with 13% for the state and 12% for the nation. The Census Bureau’s American Community Survey for 2006-2008 indicates that seniors now comprise 16.5% of the county population and projections provided by NPA Data Services indicate the group will comprise 25% of the population by 2030. Even though the number of seniors decreased between 1990 and 2000, the median age increased, going from 36 in 1990 to 38.9 in 2000. A primary factor contributing to the increasing median age is significant losses in the number of people in their child-bearing years—25-34 years—and 0 1000 2000 3000 4000 5000 6000 0‐4 5‐9 10‐1415‐1920‐2425‐3435‐4445‐5455‐64 65+ Figure 6 Age Distribution, 1980‐2000 1980 1990 2000 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐8 I P a g e subsequent decreases in the number of children. The 25-34 age cohort experienced a 29% decline between 1980 and 2000—a loss of 1,596 people. The number of children under 15 decreased by 1,941 during the same period—a loss of 18.5%. This trend correlates with the closure of elementary schools in the county and continued declines in elementary school enrollments. Another factor contributing to the increasing median age is the increase in people between the ages 35-54. People in Butte-Silver Bow who are 35-44 years of age make up the second largest age group at 15.7% of the population or 5,447 people. This group, along with those in the age group 45-54, experienced the highest gains between 1990 and 2000. This follows a national trend associated with increased births during the two decades after World War II (the “baby-boom”). The result of this trend nationally is expected to be an increase in the number of people 65 years of age and older by 2010 and through 2030. By the year 2030, the number of people 65 and older is expected to comprise over 25% of Butte-Silver Bow’s population—an approximate 9,190 people5. Recent Census estimates are indicative of the projected trend. The 2008 median age for the county is 41.8, up 2.9 years from 2000. It remains higher than both the state (39.3) and the nation (36.7). 4.2 Gender The ratio of males to females in Butte-Silver Bow has remained relatively constant over the last twenty years. Females have comprised, and continue to comprise, more than half of the general population with males comprising less than half. The 2006-2008 American Community Survey indicates that males now comprise 49.9%, which is a slight increase over the 2000 Census figure. Females now comprise 50.1% of the population. Butte-Silver Bow’s gender distribution is similar to the national distribution where females comprise 50.7% of the population and males 49.3%. 4.3 Race/Ethnicity The majority (98.3%) of the Butte-Silver Bow County population claim one race according to the American Community Survey for 2006-2008 (Census). Of those, 94.7% classify themselves as “white”. The largest single minority race is “American Indian/Alaska Native” which comprises 2.4% of the county population. Just over 1% of the population claims two races and 3.3% of the general population claim Hispanic or Latino ethnicity. 5 NPA Data Services, Inc.: Montana Population Projections, 65 Years and Over 49.90% 50.10% Figure 7 Gender Distribution Male Female ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐9 I P a g e 4.4 Households Households. There are 14,388 households in Silver Bow County according to the 2006-2008 American Community Survey. This represents a slight decrease over the 2000 Census count of households which showed a total of 14,465 households in the county. The figure is still higher than the 13,825 households counted in 1990. In addition to a smaller average family size, the county’s average household size is smaller than those of the state and the nation. While Butte-Silver Bow has an average household size of 2.19, the state posts an average size of 2.49. In the U.S., the average household size is 2.61. As the number of senior households grows and birth rates decline, the trend nationally is toward diminished households sizes. Family Households. According to the American Community Survey, there are an estimated 8,398 family households in Butte-Silver Bow County with an average size of 2.8 people per family (compared with 3.06 for Montana and 3.20 for the nation). This estimate represents a decrease over the 2000 decennial census count of families which showed 8,931 families and an average size of 2.97. In 2000, family households comprised 61.9% of total households; that number has fallen to 58.4%. The percentage of households that are families is lower in Silver Bow County than it is in Montana as a whole where family households comprise 64.3% of total state households. Nationally, family households comprise 66.6% of the population. The proportion of family households has dropped nationally as part of the aging “baby boom” trend. Butte-Silver Bow’s lower family household proportion is attributable to a lower percentage of people in the child-bearing age cohorts and a higher percentage of people over 65. 4.5 Educational Attainment The educational attainment level in Butte- Silver Bow has been steadily increasing over the last thirty years. According to 2000 Census data, 85.1% of people 25 years of age or older in the county were high school graduates, up from 78.3% in 1990 and only 69.1% in 1980. The American Community Survey indicates the figure increased to 90.7% which surpasses both the national figure of 84.5% and the state of 90.5%. (Refer to Figure 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% BSB MT US Figure 8 Educational Attainment Butte‐Silver Bow v. Montana and Nation 2008 Bachelor's Degree or Higher HS Graduate or Higher ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐10 I P a g e The percent of adults attaining a bachelor’s degree or higher in the County falls short of both the state and national figures. Although the number has risen steadily since 1980 going from 14.2% to 22.5% in 2008, the number lags behind the national and state figures which are both above 27%.6 5.0 Population Projections Future growth in Butte-Silver Bow County is likely to be contingent upon the in-migration of new residents rather than natural (internal) growth. The number of births occurring in the county has been on the decline since 19787 and the greatest decrease among age groups is occurring among those most likely to bear children—those in the age group of 25-34 years old. (The average age at which an American woman gives birth is 25.18 and the average age of a parent with children under 6 is 33.19.) In-migration will inevitably be linked to economic development and the creation of new job and investment opportunities. Some in- migration to Silver Bow County may be tied to general growth in the Rocky Mountain West as city dwellers seek alternatives to urban life styles. Lower property values in Silver Bow County could potentially attract investment interest as rising housing costs and property values in more rapid growth areas in Western Montana drive buyers to lower-priced markets. Lack of natural growth potential has created population estimates and projections indicative of decline. In addition to Census estimates showing decline, NPA Data Services, Inc. has projected continued decline for the county into the year 2015, after which a period of slight growth is projected. Using their assumptions, although gaining, the county will remain short of its 2000 population by 2030. (Refer to Figure However, there may be realistic potential for growth that is linked to job creation, particularly in technology and health care related industries. The number of people employed in health care-related jobs has increased by 40% since 1995 in Silver Bow County10 and location quotients for the health care industry indicate that new dollars are generated in the community through health services11. Further, it is expected that 16% of all 6 U.S. Census Bureau; Census of Population and Housing; 1980, 1990, 2000; American Community Survey, 2006‐2008 7 Montana Department of Public Health and Human Services; Annual Frequency of Live Births by Mothers County of Residence; 1978‐ 2003 8 Kaiser Daily Reproductive Health Report; December 18, 2003; “Average Age of First Birth Reaches Record High of 25 CDC Report Says. 9 Parents Action For Children Website; “Key Facts About Parents in America”; 2005 10 US Census Bureau; County Business Patterns for Silver Bow, Montana; 1995‐2000 11 Montana Department of Labor and Industry‐Research and Analysis Bureau; Silver Bow County Location Quotients 34,606 32,652 32,160 31,720 31,590 31,850 32,400 30,000 31,000 32,000 33,000 34,000 35,000 2000 2007 2010 2015 2020 2025 2030 Figure 9 Population Projections NPA Data Services, Inc. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐11 I P a g e new wage and salary jobs created nationally between 2002 and 2012 will be in the health care industry12. This is due in part to the increasing number of people 65 years of age and older. As the number of older people increases, so does the demand on the public health system, medical and social services13. This is of particular note in Butte-Silver Bow where the median age is already higher than both the state of Montana and the nation and where senior citizens are expected to make up 25% of the population by 2025—an increase of an approximate 3,000 people in the 65+ age cohort14. Continued success in technology-related businesses is also cause for optimism as are investments being made in vacant structures in the historic uptown district. As presented in the Butte-Silver Bow Growth Policy (2008 Update) and Butte Transportation Plan (2005 Update), the following three Tables 3 and 4) present three scenarios for population growth between 2005 and 2025. The 2005 population figure presented in the Tables is more optimistic than recent Census estimates which show the county population in a state of decline. The figure is representative of renewed growth in the total number of jobs in the county after 2001 and a ratio of jobs to population that is more reflective of similar historic periods of low unemployment. In the low-growth scenario, Butte-Silver Bow gains 1,046 people between 2005 and 2025 for a 3% rate of growth. The moderate growth scenario shows a gain of 2,113 people for a 6% rate of growth, and the high growth scenario presents a 12% growth rate for a gain of 4,287 people over the 20-year period. 1. Low Growth Scenario: 3% growth between 2005 and 2025 Table 2 Population Projections 2005-2025 2005 Projected Population Percent Change 2000- 2005 2015 projected Population Gain/ Loss Percent Change 2005-2015 2025 Projected Population Gain/ Loss Percent Change 2015-2025 34,688 +0.2% 35,207 519 +1.5% 35,734 527 +1.5% Total Population Gain: 1,046 12 United States Department of Labor; 2004‐05 Career Guide to Industries, Health Services; Bulletin 2541 13 Centers for Disease Control; Article, “Public Health and Aging: Trends in Aging‐ United States and Worldwide”, 2‐14‐03 14NPA Data Services, Inc.: Montana Population Projections, 65 Years and Over ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐12 I P a g e 2. Moderate Growth Scenario: 6% growth between 2005 and 2025 Table 3 Population Projections 2005-2025 2005 Projected Population Percent Change 2000- 2005 2015 projected Population Gain/ Loss Percent Change 2005-2015 2025 Projected Population Gain/ Loss Percent Change 2015-2025 34,688 +0.2% 35,729 1,041 36,801 1,072 Total Population Gain: 2,113 3. High Growth Scenario: 12% growth between 2005 and 2025 Table 4 Population Projections 2005-2025 2005 Projected Population Percent Change 2000- 2005 2015 projected Population Gain/ Loss Percent Change 2005-2015 2025 Projected Population Gain/ Loss Percent Change 2015-2025 34,688 +0.2% 36,769 2,081 38,975 2,206 Total Population Gain: 4,287 Under the 3% growth scenario, the number of households in the county will reach approximately 15,175 by 2015 and 15,402 by 2025 for a twenty-year gain of 451 households (assumes a stagnant average household size). Assuming a continued decline in the percentage of population in families, there will be an estimated 9,085 families by the year 2025, a gain of 115 families over the 20-year period. (Refer to Tables 5 and 1. Number of Households into 2025 Table 5 Household Projections 2005-2025 2005 Projected Population Avg. HH Size 2005 Projected Households 2015 Projected Population Avg. HH Size 2015 Projected Households 2025 Projected Population Avg. HH Size 2025 Projected Households 34,688 2.32 14,951 35,207 2.32 15,175 35,734 2.32 15,402 Total Gain in Households: 451 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐13 I P a g e 2. Number of Families into 2025 The percentage of the population comprised of people 65 years of age and older is expected to grow significantly in Butte-Silver Bow County into 2025. This is attributable to an elevated birth rate during the two decades after World War II (the “baby boom”) that is expected to result nationally in an increase in senior citizens by 2010 and through 2030.15 Locally, seniors are projected to grow to 25% of the population by 2025 compared to the national projection of 18.39%16. Assuming a 3% population increase, the number of seniors would grow to 8,933 seniors by 2025, an increase of 3,175 people in the age cohort over the 20-year period. (Refer to Table 1. Number of People 65 Years and Older into 2025 Table 7 Number of Seniors - Projections 2005-2025 2005 Projected Population % of Pop. 2005 Projected Seniors 2015 Projected Population % of Pop. 2015 projected Seniors 2025 Projected Population % of Pop. 2025 Projected seniors 34,688 16.6 5,758 35,207 20.4 7,182 35,734 25 8,933 Total Gain in Seniors: 3,17517 15 Centers for Disease Control; Article, “Public Health and Aging: Trends in Aging‐ United States and Worldwide”, 2‐14‐03 16 NPA Data Services, Inc.; Montana Population Projections, 65 Years And Over; November 17, 2006 17Percentages projected by NPA Data Services, Inc. were applied to a 3% population growth scenario taken from the Butte‐Silver Bow Transportation Plan Update, 2005 Table 6 Number of Families - Projections 2005-2025 2005 Projected Population % of Pop. 2005 Projected Families 2015 Projected Population % of Pop. 2015 projected Families 2025 Projected Population % of Pop. 2025 Projected Families 34,688 77% 9,054 35,207 76% 9,070 35,734 75% 9,085 Total Gain in Families: 115 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐14 I P a g e II. SOCIOECONOMIC AND HOUSING FACTORS 1.0 Median Household Income (MHI) Median Household Income (MHI) in Butte-Silver Bow County lags far behind the median for the nation. At $37,346, MHI is at a mere 71.6% of the national figure ($52,175). While the dollar figure has risen over time, the County figure continues to grow more slowly than the national figure.18 A closer look at the income distribution illustrates that Butte- Silver Bow County is weighted toward the lower income cohorts. Over 46% of households in the County have incomes that are lower than $35,000 compared with just under 40% for Montana and just under 34% for the nation. (Refer to Figure 12.) Thirty-seven percent (37%) of the county population has an annual income at or below the federal poverty line making them eligible for a number of federal programs. Of notable concern is the disparity in MHI within segments of the Butte community. According to the 2000 Decennial Census (the most recent data available below the county level), MHI ranged from $12,141.00 in Block Group 4 of Census Tract 1 to $57,000.00 in Block Group 4 of Census Tract 8. Thirty-three percent (33%) of all Census Block Groups (14 out of 43) had an MHI below 70% of the national figure. Nine of these Census Block Groups had an MHI below 55% and represent the very poorest areas in the county, all posting poverty rates well above the overall county rate. Six of the nine areas are located in Butte’s older town site in Census Tracts 1 and 2. (Refer to Table Census Tracts 7 and 8 posted the highest median household incomes in 2000; they were at or above the national figure. Block groups within those tracts that contribute to the higher incomes are Tract 7, Block Group 3 which encompasses the Country Club and the general area between Mount Highland Drive and Elizabeth Warren Avenue, and Block Group 4 of Tract 8, particularly the Blacktail Loop area. 18 U.S. Census Bureau: American Community Survey; 2006‐2008 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% Less than $10,000 $10,000 to $14,999 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to … $150,000 or more Figure 10 Income Distribution Silver Bow County v. Montana and Nation U.S. Butte‐Silver Bow Montana ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐15 I P a g e 2.0 Poverty The poverty rate in Butte-Silver Bow is higher than rates for both the State of Montana and the nation and is on the rise. The overall poverty rate in Butte-Silver Bow is 15.4%, up from 14.9% in 2000. Nationally, the total population living below the federal poverty line is 13.2%; in the state of Montana overall, 14.1% live below the poverty. (Refer to Table 11.) That poverty is on the rise is evidenced by an increased demand at the Butte Emergency Food Bank. The average number of clients served per month in 2009 is up 9% over 2008. The average number of people served per month in 2009 was 1,467 up from an average of 1,345 in 2008.19 Additionally, 15% of the population in Butte-Silver Bow has health care costs covered by Medicaid compared with 11% statewide.20 As indicated by 2000 Census data that is presented at the Tract and Block Group level, there are pockets of deep poverty within the County. Forty percent of Butte-Silver Bow’s Census Block Groups (17 out of 43) had poverty rates higher than the overall county rate in 2000 that ranged from 15% to 61%. Of the 17 high- poverty Block Groups, ten (or 59%) were located in Census Tracts 1 and 2, inside the older town site. These 19 Butte Emergency Food Bank Statistics, 2010 20Montana Department of Health and Human Services; 2009 Silver Bow County Health Profile Table 8 Areas with Lowest Median Household Incomes Location MHI Percent of National Census Tract One, Block Group 4 $12,141 28.91% Census Tract One, Block Group 5 $15,781 37.58% Census Tract One, Block Group 6 $21,977 52.33% Census Tract One, Block Group 7 $12,708 30.26% Census Tract Two, Block Group 1 $20,265 48.26% Census Tract Two, Block Group 2 $20,714 49.33% Census Tract Four, Block Group 6 $21,583 51.40% Census Tract Six, Block Group 2 $21,875 52.09% Census Tract Six, Block Group 3 $21,920 52.20% Tract 1 33% Tract 2 18% Tract 3 4% Tract 4 6% Tract 5 7% Tract 6 19% Tract 7 5% Tract 8 8% Figure 11 Poverty Distribution ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐16 I P a g e two tracts contain 52% (2,550 people) of the county’s poor while containing only 29% of the total population. (Refer to Figure 13.) Of particular note are Block Groups 4 and 5 in Tract 1 where poverty rates were 47% and 61% respectively in 200021. High concentrations of poverty in these areas correlate with high concentrations of blighted housing. The rate of childhood poverty in Butte-Silver Bow also appears to be on the rise. The 2008 Census estimate indicates that 20.4% of children (under 18 years of age) are living below the federal poverty line, up from 19.2% in 2000. Like the overall poverty rate, the rate of childhood poverty is also higher in Butte-Silver Bow than it is nation as a whole. (Refer to Table 10.) 3.0 Housing Factors 3.1 Age and Condition According to 2000 Census data, the largest number of housing units (41% or 6,556 units) in Butte-Silver Bow County was constructed prior to 1939. The community experienced construction surges in the 1950’s and again in the 1970’s, but none to the extent that occurred prior to 1939; the 1950’s saw construction of 2,094 units and 2,384 units were built during the 1970’s. Nearly 60% of units built prior to 1939 are contained in the old town site in Census Tracts 1 and 2.22 (Refer to Figure 12.) Butte-Silver Bow added 1,358 new units to its housing stock during the 1990’s. The majority 21 U.S. Bureau of the Census; Census of Population and Housing, 2000 22 U.S. Census Bureau; Census of Population and Housing, 1990, 2000 Table 10 Childhood Poverty Rates Place 2000 2008 Estimate Butte-Silver Bow 19.2% 20.4% Montana 18.4% 19.2% United States 16.1% 18.2% Source: U.S. Census Bureau, Census of Population and Housing, 2000; Small Area Income & Poverty Estimates, 2008 0 1000 2000 3000 4000 5000 6000 7000 1939 or earlier 1940‐1949 1950‐1959 1960‐1969 1970‐1979 1980‐1989 1990‐1994 1995‐1998 1999‐3/2000 Figure 12 Year of Construction for Housing Units Units ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐17 I P a g e of new units were added in Census Tracts 6, 7 and 8. These three Census Tracts also posted the highest growth rates with regard to both population and occupied housing units during the decade 1990-2000. As pointed out in the population analysis, growth in these areas of Butte tends to consist of low density housing in semi-rural settings that are far from job and service centers. A continued pattern of growth in areas peripheral to the urban core creates a number of secondary issues of a public health nature that include higher use of roadways, increased emissions from cars as people live further from employment centers and an increased reliance on cars that discourages walking. The mean travel time to work increased by 3.5 minutes between 1990 and 2000, going from 10.8 minutes to 14.3 which means people are spending more time in cars, adding to the potential for higher crash and fatality rates and discouraging walking or cycling to work, amenities and services, thereby potentially contributing to obesity. The growth pattern also strains emergency services as response times grow and infrastructure as density increases in the more rural areas outside the urban cluster. While the newer areas of the community have experienced new construction and growth, the age and condition of housing stock in the older town site present a vital planning and public health challenge for Butte-Silver Bow. Of the 3,561 housing units in Butte-Silver Bow that are reported to be in unsound to fair condition as reported in 2005 by the Center for Applied Economic Research, an approximate 74%, or 2,635 units, are contained in Census Tracts 1 and 2. This is based upon a visual estimate of structures in the area that have clear structural and maintenance issues. According to the February, 2005 study prepared for the Montana Department of Commerce, the 3,561 units in unsound to fair condition represent 28% of Butte’s overall housing stock. This is compared to 24% for Montana overall. Another 37% of Butte-Silver Bow units (approximately 4,743 units) are in only average condition. Blight in Census Tracts 1 and 2 is attributable to the age of the units as well as flight of middle and upper income households from the area. The median year of construction for units in all Census Block Groups Figure 13 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐18 I P a g e contained in Tracts 1 and 2 is 193923. The large majority of units are nearly 70 years old, but many were constructed over 100 years ago. A concentration of poorer households in these parts of the community has, by virtue of limited resources, translated into lack of investment in maintenance and upkeep of units. Perhaps of more importance is the resulting isolation of poor households in the most blighted and unsafe area of the urban cluster. Segregation of the poor represents a paradigm shift away from economically diverse neighborhoods that once characterized the community. Decay of the housing stock in much of Census Tracts 1 and 2, which encompass the area north of Front Street to Walkerville and the upper and lower west sides of the urban cluster, are contributing to a significant aesthetic crisis, have created an economic development barrier for the community and present potential public health problems. Unsafe housing and infrastructure in crumbling neighborhoods throughout this area of Butte have the potential to contribute to poor health. The high concentration of mobile homes in pockets of the county is also presents a public health challenge. Butte-Silver Bow’s housing stock includes 1,570 mobile homes, the majority of which are located in Census Tracts 4, 6 and 8. Sixty percent (942 units) of the county’s mobile homes were constructed prior to the enactment of the National Manufactured Housing and Safety Standards that took effect in 1976. While these units offer an affordable housing alternative to stick-built homes for lower income households, they are all too often the most substandard, unsafe and energy consumptive housing option24. 3.2 Senior Citizen Housing Of particular note in the analysis of housing trends in Butte-Silver Bow County is the number of homeowners who are 60 years of age and older. In addition to representing the largest age cohort in the county, senior citizens comprise the single largest group of homeowners. Thirty-seven percent of owner-occupied units are occupied by householders in this age group. Seventy- nine percent of householders in the 60+ age group are homeowners and they occupy 3,779 housing units. As this age group grows in association with the ‘baby boom’ into 2030 23 U.S. Census Bureau; Census of Population and Housing, 1990, 2000 24 Mobile Home Decommissioning & Replacement and Mobile Home Park Acquisition, Strategies for Montana; Preliminary Analysis and Report; by Community Development and Management Services; Rand Kennedy and Julie Authors 0 10000 20000 30000 40000 50000 2005 2010 2015 2020 2025 Figure 14 Senior Population into 2025 Population People 65 and older ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐19 I P a g e and occupies an ever-increasing percentage of the population, providing for their housing needs will become paramount to community planning efforts. 25 Planning for the needs of the county’s seniors should consider trends for the aging population nationally. Foremost among those trends is the provision of services that allow seniors to age in place. According to Harvard University’s Housing America’s Seniors, only 10 percent of seniors lived in age-restricted communities in 2000. However, the Harvard study noted that the existing housing stock is not designed to meet the changing needs of seniors as they age. As a result, the market for home modifications and healthcare and other supportive services to help older Americans live safely and comfortably in their homes is large and growing. Yet, much of the current demand for modifications is unmet. Only about half of those who are over 65 with disabilities have the modifications they believe they need. (Schafer) The Harvard study also pointed to the need for housing to accommodate senior couples as men begin to live longer and the need for “walkable” neighborhoods that provide amenities and entertainment within walking distances. Survey data associated with the study indicates that home buyers aged 45 and older, who prefer denser, more compact housing alternatives will account for 31% of total homeowner growth between 2000 and 2010, double the same segment’s market share in the 1990s. 3.3 Neighborhoods The impact of high poverty neighborhoods on a community should be factored into the assessment of public health. Social isolation results when there is a high concentration of impoverished people in a neighborhood who have little opportunity for interaction with conventional role models. Where this occurs, people are influenced by behavior, social perceptions, belief and orientations of similar people disproportionately concentrated in the neighborhood.26 All too often, these orientations include a lack of attachment to the work force and social dysfunctions like drug and alcohol abuse, domestic violence and other behaviors that create intractable barriers to social mobility. Author and prominent sociologist Julius Wilson holds, “The lack of economic and social resources in the neighborhood produces outcomes that restrict social advancement.” “Some of these outcomes are structural (weak labor force attachment) and some are social- (low aspirations).” “Social isolation deprives inner city ghetto residents not only of economic and social resources including conventional role models whose presence buffers the impact of neighborhood joblessness, but also of 25 Source for Tenure data was the U.S. Census Bureau; Census of Population and Housing, 1980, 1990, 2000 26 Poverty and Inequality, Chapter 5, Social Theory and the Concept of Underclass; William Julius Wilson ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐20 I P a g e cultural learning from mainstream social networks that facilitate economic and social mobility in modern society.27 Impoverished neighborhoods in Butte’s urban cluster have characteristics analogous to what Wilson describes as the “urban underclass”. A high concentration of poverty is accompanied by a high concentration of single- parent households, high unemployment, a low percentage of adults in the labor force, low educational attainment and an elevated high school drop-out rate. These factors can be found in Census Tract One, particularly in Census Block Groups 4 and 5 which happen to have the highest poverty rates in the County (47% and 61%). Table 11 below illustrates characteristics of Butte’s oldest neighborhoods. 27 Poverty and Inequality, Chapter 5, Social Theory and the Concept of Underclass; William Julius Wilson Table 11 Neighborhood Characteristics Block Group 4 Block Group 5 Census Tract One Silver Bow County Race 91% White 94% White 91% White 96% White Poverty Rate (2000) 47% 61% 34% 14.3%* Median Household Income (2000) $12,141 $15,781 $18,673 $30,402 Median Age 33 34 35.6 38.9 % of Population at 120% or Less of AMI 63.9% 85.4% 76% 60% % of Population at 50% or Less of AMI 61% 65% 46% 51% % Single Parent Households 59% 30% 41% 28% % Single Parent Households Below Poverty 91% 79% 64% 41% % Family Households w/Children Below Poverty 54% 76% 40% 18% % of Poor Households Headed by Single Parent 100% 31% 65% 64% Unemployment Rate 12%* 12%* 11%* % of Adults not in Labor Force 61% 32% 45% 38% % 16-19 Year-olds Not in School/Not Graduates 13% 60% 23% 7% % Not High School Graduates 22% 39% 23% 15% Sources: U.S. Census Bureau, 2000; *U.S. Census Bureau; 2000 (no recent unemployment data available); the 2000 was used for comparison purposes here because there is no current poverty data on the Block Group or Tract level; the estimated County poverty rate for 2007 is 15.3%. **Current Unemployment Rate; Montana Department of Labor ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐21 I P a g e III. SOCIAL AND BEHAVIORAL FACTORS 1.0 Crime According to 2009 data provided by the Montana Board of Crime Control, Butte-Silver Bow has the highest crime rate among the seven major counties in Montana including Cascade, Flathead, Gallatin, Lewis & Clark, Missoula, Silver Bow and Yellowstone. The crime rate encompasses the seven index crimes per 100,000 people including homicide, rape, robbery, aggravated assault, burglary, larceny and motor vehicle theft28. The county has a higher rate of domestic abuse crimes than any other major county in the state and the highest rate of reported drug offences per 100,000 people. Refer to Table 12 for specific data. Table 12 Crime Data County Crime Rate (per 100,000) Domestic Violence Crimes (per 100,000) Drug Offenses (per 100,000) Cascade 3663.[PHONE REDACTED] 337.0117 Flathead 3561.[PHONE REDACTED] 630.3407 Gallatin 2499.[PHONE REDACTED] 724.9822 Lewis & Clark 2602.[PHONE REDACTED] 448.89 Missoula 2866.[PHONE REDACTED] 559.0039 Silver Bow 4873.[PHONE REDACTED] 736.106 Yellowstone 4089.[PHONE REDACTED] 564.0523 Source: Montana Board of Crime Control; 2009 Interactive Historic Crime Data 2.0 Child Well-Being Indicators of child well-being in Butte-Silver Bow point to a rather high degree of distress among the child population. From a public health perspective, widespread distress among children cannot be viewed independently of the environment in which the distress is occurring. Several community factors are thought to place children at risk. A combination of factors including high crime rates, high rates of domestic violence and substance abuse, norms favorable toward substance abuse, availability of alcohol and other drugs and extreme economic deprivation are thought to contribute to a high risk environment for children. In an analysis of eight indicators of child well-being in 2006 completed for purposes of the local Kids Management Authority, the county ranked number one among Montana’s seven major counties for childhood distress. Butte-Silver Bow received a ranking of ‘one’ in four of eight categories including the 28 Montana Board of Crime Control; 2009 Crime Report; County Tables ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐22 I P a g e poverty rate for the population under 18 years of age (2000 Census), the percentage of children living in high-poverty neighborhoods (2000 Census), the average number of food stamp recipients per month (2002) and the number of substantiated child abuse cases per capita (2003). The county ranks second only to Cascade County in the number of out-of-home placements per capita made by the Department of Public Health and Human Services (2003)29. (Refer to Table 13.) In January, 2009, 98 children in Butte-Silver Bow were in out-of-home placements through court order due to abuse or neglect.30 This figure represents a rate of 13.6 per 1000 children, well above the national abuse rate of 12.1.31 The figure did not include children in the county who were still in their homes but on whose behalf Child Protective Services had intervened due to substantiated maltreatment issues. That figure was not available at the time of this report. In over 80% of these cases, substance abuse was indicated as a factor.32 The number of children in Silver Bow County for whom sexual abuse is indicated is also of concern. The Butte Child Evaluation Center, located in the Butte Community Health Center, evaluated 318 Butte children between 2007 and 2009 for whom sexual abuse was indicated.33 This represents 4.42% of children under 18 in the County. The apparent risk to children developing Butte’s relatively high-risk environment is evident in the number of children suffering from Severe Emotional Disturbance (SED). In 2006, according to information provided by the local Kids Management Authority, there were an estimated 477 children in the county being treated for SED which places the prevalence rate at 11 percent. Taking into account children who have not yet been diagnosed, the rate is likely between 11 and 13 percent. The local rate is significantly higher than the national prevalence rate of 5 to 9 percent (Friedman et al., 1996). 29 Rankings are based on figures provided by the Bureau of Business & Economic Analysis, University of Montana; 2004 Kids Count County Data and Reference Bureau, analysis of data from the U.S. Census Bureau, for The Annie E. Casey Foundation. Each county was given a ranking for each of eight indicators, the number one assigned to the highest rate among seven counties, and the number seven given to the lowest rate among seven counties. The eight rankings were summed for a total score. The lowest score indicated the highest ranking. Butte‐Silver Bow had the lowest score in the final tally. 30Montana Department of Health and Human Services; 2009 31 Child Trends Data Bank; 2005 32Montana Department of Health and Human Services; 2009 33 Butte Community Health Center, Behavioral Health Division ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐23 I P a g e The extent to which youth in Butte-Silver Bow County are engaged in high risk behaviors also provides an indication of the community risk environment. The 2008 Montana Prevention Needs Assessment (PNA) reveals some startling information about behaviors of youth in the County. The number of youth in 10th grade having ever used alcohol, having used alcohol in the 30 days prior to the related survey, and those engaged in binge drinking within two weeks of the survey was higher in the County that it was for the state of Montana overall. Nearly 30% of tenth grade students indicated they had engaged in binge drinking which means they had had five drinks or more in a row within two weeks of the survey. This number increased for twelfth grade students in the 2008 survey. Just under half of youth in twelfth grade in 2008 indicated they had engaged in binge drinking within two weeks of the survey. The PNA indicates that the percentage of youth engaged in binge drinking progressively increased between eighth grade and twelfth indicating a progression of high risk behaviors through high school. This pattern is generally true with cigarette smoking, use of chewing tobacco and use of marijuana as well. (Refer to Figures 15 and 16.) The 2008 PNA also provided information about community, family and peer characteristics that are thought to predict the likelihood of drug use and other problem behaviors. Just over half of youth in eighth grade had 8 or more risk factors placing them at high risk for problem behaviors. By twelfth grade, over 60% of students were at high risk which means they had 9 or more risk factors at work in their lives. A risk factor that was common to all three grade levels for which the survey was completed in 2008 and that stands out 0% 10% 20% 30% 40% 50% 8th grade 10th grade 12th grade PERCENTAGE OF KIDS Figure 15 Youth Engaged in Binge Drinking Source: 2008 Montana Prevention Needs Assessment 0% 10% 20% 30% 40% 50% 60% 70% 8th grade 10th grade 12th grade PERCENTAGE OF KIDS Figure 16 Use of Substances within 30 Days of Survey Source: 2008 Montana Prevention Needs Assessment Alcohol Cigarettes Chewing Tobacco Marijuana ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐24 I P a g e in data related to risk factors is the degree to which parents have favorable attitudes toward anti-social behaviors including alcohol use. This figure in Butte-Silver Bow is significantly higher than the state in twelfth grade. Another piece of data that is of concern is the increase in the percentage of youth by twelfth grade who have a low commitment to school. Over 60% of twelfth grade students in 2008 indicated this in the 2008 survey. Only an approximate 55% of seniors indicated a high degree of protection from problem behaviors in the survey which is nearly 10 percentage points lower than the overall figure for the state of Montana. 3.0 Substance Abuse and Driving Butte-Silver Bow County has a deeply rooted culture of substance abuse that presents a risk to public health. This culture must be understood within Butte’s origins as a mining camp. Butte grew into a community because of its abundance of underground copper that drew industrialists and miners to the area. For over 100 years, Butte was a mining camp that rode the ups and downs of the copper industry. Technological and Table 13 Indicators of Child Well-being, Comparison of major counties in Montana Poverty: Silver Bow Cascade Gallatin Flathead Lewis & Clark Missoula Yellowstone Poverty Rate for Population <18 19.5 19.2 11.2 17.3 13.5 15.2 15 % of Children in High-poverty Neighborhoods 29.6 11.9 5.8 9 14.5 23.4 13 Avg. # of Families/mth on TANF-Per Capita 0.0082 0.0068 0.0024 0.0057 0.0094 0.0053 0.0098 Avg. # of Families/mth on Food Stamps- Per Capita 0.0957 0.0696 0.0234 0.0596 0.0618 0.0665 0.0602 Child Abuse/Neglect: Substantiated Child Abuse Reports Per Capita 0.0017 0.0017 0.0005 0.0006 0.0009 0.0006 0.0007 Out-of-Home Placements Per Capita (April, 2006) 0.00365 0.00378 0.00060 0.00130 0.00230 0.00153 0.00265 Adolescent Behaviors: % of Population 16-19-High School Drop-outs 6.9% 7.4% 4.7% 7.9% 5.9% 5.7% 8.2% % of Population 16-19 Not in School/Not Working 7.3% 9.9% 3.2% 7.8% 4.8% 3.9% 5.8% Number of Juvenile Offenses Per Capita 0.0200 0.0369 0.0188 0.0078 0.0236 0.0203 0.0100 Sources: Bureau of Business & Economic Analysis, University of Montana; 2004 Kids Count County Data. Population Reference Bureau, analysis of data from the U.S. Census Bureau, for The Annie E. Casey Foundation. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐25 I P a g e structural economic changes eventually led to a significantly diminished role for copper mining in Butte, but its mining legacy lives on. For many, over eighty years of economic depression have resulted in multi- generational poverty that is highly entrenched and seemingly intractable. In addition, values and behaviors known to evolve in mining settlements continue to be woven into the social fabric of Butte, not the least of which is a cultural acceptance of alcohol abuse. The culture of alcohol abuse is well known among Butte citizens and the community’s reputation throughout Montana as a “hard drinking” town is not without merit. While the rate of alcohol abuse is difficult to quantify, the number of DUI crimes that is tracked through the Montana Board of Crime Control is one indicator. According to that data, the 2008 rate of DUI crimes per 100,000 people was up 135% over the 2004 rate. The extent to which more effective policing and reporting is impacting the numbers is not known. However, it bears noting that the local 2008 DUI crime rate per 100,000 people was nearly 20% higher than the rate for Montana overall. (Refer to Figures 17 and 18.) The situation does not appear to be improving. Local data reveals that there is an average of 31 DUI convictions per month in Butte-Silver Bow County; between January 1, 2008 and March 19, 2009, there were 450 convictions.34 This rate indicates a 24% increase over the 2008 rate provided by the Montana Board of Crime Control data. Perhaps most alarming is that 35% (156) of those convictions were repeat offenders (Refer to Figure 19). Butte-Silver Bow law 34 Butte‐Silver Bow Law Enforcement 65% 18% 7% 10% Figure 19 Number of DUI Offenders January 1, 2008 ‐ March 19, 2009 1st Offense 2nd Offense 3rd Offense 4th or More 0 200 400 [PHONE REDACTED] 2004 2005 2006 2007 2008 Number of Crimes per 100,000 people Figure 18 DUI Crimes Silver Bow County v. Montana MT DUI Crimes Silver Bow Co. DUI Crimes 0.0 200.0 400.0 600.0 800.0 1000.0 2004 2005 2006 2007 2008 Figure 17 Silver Bow County DUI Crime Rate (per 100,000 people) Source: MT Board of Crime Control ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐26 I P a g e enforcement data indicates that 75% of offenders incarcerated for DUI are substance dependent, 30% of whom are in need of medical detoxification. The high risk behaviors create a threat to public health on the roadways. Butte, like all of Montana, has a high rate of vehicle ownership and sparse public transit services. Thus, a significant number of people rely on cars as a primary mode of transportation. By virtue of driving in a rural area, the likelihood of crashing is increased. According to the Montana Highway Safety Bureau (Traffic Safety Problem Identification, 2009), “a high percentage of miles traveled (in Montana) are at rural speeds compared to more urban states, thereby increasing the likelihood of crashes.” Driving challenging roadways in the Butte area present an added risk. According to the Montana Department of Transportation’s “Five Report”, the Butte area has in its road system several identified “high crash severity corridors”. Two sections of Interstate Highway 90 (I-90)—Warm Springs to Ramsay and Continental Drive to Pipestone—are designated as such as is the rural state primary route of Pipestone Pass south of Butte and the urban state primary route of Harrison Avenue to Montana Street inside the urban cluster.35 (Refer to Table 14.) These routes are well traveled by local residents. I-90 heading both west and east are used heavily by people commuting to job centers at Warm Springs State Hospital, the industrial park west of Butte and the Golden Sunlight Mine located east of Butte near Whitehall. For surrounding rural town centers like Ramsay, Butte is a retail center making highway travel for provisions necessary. Harrison and Montana Avenues are major routes connecting residents to job and retail centers. For these and other reasons, portions of the highway system around and in Butte are challenging for drivers and require drivers to be alert and cautious. When an impaired driver takes to these challenging roadways, crash potential rises dramatically. Research has documented that the risk of a motor vehicle crash increases as blood alcohol concentration (BAC) increases. According to the National Institute on Alcohol Abuse and Alcoholism, “a driver with a BAC of between 0.05 and 0.09 percent is 11 times more likely to be involved in a fatal motor vehicle crash than a driver who has not consumed alcoholic beverages; a driver with an alcohol concentration of 0.10 to 0.14 percent is about 48 35 Montana Department of Transportation “Five Percent Report”, August, 2009 Table 14 High Crash Severity Corridors (Source: MDT Five Percent Report) Highway Section Category I-90 Warm Springs to Ramsay Rural Interstate I-90 Continental Drive to Pipestone Rural Interstate P-29 Pipestone Pass Rural State Primary Route P-29 Butte-Harrison Ave./Montana Ave. Urban State Primary Route ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐27 I P a g e times more likely to be involved in a fatal crash.”36 On roads where the driving task is more demanding like some of the challenging roadways in the Butte area, even lower BACs pose a risk for crashes. The combination of challenging roadways, high vehicle use and a propensity for alcohol abuse in Butte-Silver Bow County creates a high risk condition for crashes and fatalities. According to 2007 crash data made available through the Traffic Safety Problem Identification system, there were 46 alcohol related crashes in Butte-Silver Bow County. Although this represents only 7% of total crashes37, local officials fear the potential is great for the scenario to grow worse. 4.0 Homelessness The level of homelessness in Butte-Silver Bow is currently at an approximate 0.25% of the population; this level has persisted since 1994 when the first homeless count was conducted in June of 1994. At that time, 76 people were found to be homeless, most of whom were residing at the local emergency shelter (the Butte Rescue Mission), at Safe Space (the local domestic violence shelter), or were living in cars or other places not meant for human habitation. Since that time, the community has developed a transitional housing program (Homeward Bound) and through this vehicle, the community continues to conduct annual counts and participates in a statewide homeless prevention effort (the Montana Continuum of Care Committee). The most recent homeless count conducted in January, 2006 revealed 37 homeless people in Butte-Silver Bow. The figure includes 3 families or 10 people and 28 individuals. Twenty-eight of the homeless people counted were staying in transitional housing, 3 were sleeping outside, 4 were in emergency shelter and 2 were staying in motels made available through a voucher. The number of homeless in 2006 is similar to 2005 when 28 individuals and 5 families were considered homeless.38 While these numbers are down from the 1994 count, it is likely due to the timing of the homeless count. Prior to 2005, counts were conducted in spring or summer when counts tend to be higher. The number of people being served annually in the local transitional housing program provides an indication that the level of homeless remains close to the 1994 level. The average number of people served at Homeward Bound has remained between 86 and 96 over the past twelve years. 36 National Institute on Alcohol Abuse and Alcoholism ; No. 31 PH 362 January 1996 37 Montana Department of Transportation; Traffic Safety Identification 38 Montana Continuum of Care Committee; Annual Statewide Homeless Count, 2005 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐28 I P a g e IV. ENVIRONMENTAL FACTORS39 1.0 Air Quality Air quality during Butte’s early history was primarily impacted by mining activities. During the latter portion of the 19th Century and into the 20th Century, copper mining and ore processing activities (13 active smelters and heap roasting of the copper ore) resulted in air quality problems that were causing significant damage to public health and the environment. Butte-Silver Bow had the first air quality ordinance in the United States dating back to the late 1890’s. As a result, limited monitoring and enforcement occurred until the environmental movement in the late 1960’s and early 1970’s brought air quality issues to the forefront. Today, the majority of air quality concerns in Butte-Silver Bow are the result of small particulate matter (PM) being released into the ambient (outside) air. Particulate matter has been monitored in Butte since 1971. Additional studies and rule changes promulgated by the EPA have led to the most recent National Ambient Air Quality Standards (NAAQS). 1. PM-10 (1987): Particulate matter 10 microns in size or less (width of a human hair). A Chemical Mass Balance Study was done to determine the major sources of PM-10 and how those concentration results compared to the new NAAQS. The results showed residential wood burning, road dust, and diesel engines were the major contributors to the PM-10 problem. Butte was found to be in non-compliance with the new standards. A new air quality ordinance and educational program was enacted to address residential wood burning and idling diesel engines, along with a more effective street sweeping and flushing program. Commercial and industrial sources (i.e. Montana Resources, asphalt plants, etc.) are regulated by the State of Montana’s Department of Environmental Quality. With these efforts, Butte has not violated these standards for many years. 2. PM-2.5 (2006): Particulate matter 2.5 microns in size or less. These particles are most often associated with incomplete combustion sources. Another Chemical Mass Balance Study was done in the winter of 2007/2008. The results showed residential wood burning, auto/diesel exhaust and sources from industrial activities as the largest contributors to PM-2.5 concentrations. Butte is not in violation of the new standards at this time, but monitoring has showed we are very close to violating the standards. A new ordinance and other control measures are being developed to further address issues associated with PM-2.5 standards. 39 Report provided by Dan Powers, Butte‐Silver Bow County Health Department, Environmental Health Division ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐29 I P a g e The issue of air quality with regard to pm-2.5 should be understood within the context of land use planning. The demographic analysis provided in 1.3 of this chapter illustrates that a significant shift in the county population has occurred that places more people at further distances from work centers and amenities. Housing and associated population growth on the periphery of the urban cluster and simultaneous population decline within the urban cluster point to more travel time to work, and therefore, more auto emissions. In recognition of this phenomenon, the Butte-Silver Bow Growth Policy calls for housing development that is close to employment centers and infrastructure. 3. Particulate air quality monitoring occurs daily at the Greeley School site. Real time (minute by minute) data is available, and is used in the event an air quality alert is issued. 4. Education is also a major component of the program. Air quality information is posted on the State’s Department of Environmental Quality (DEQ) website; www.deq.mt.gov as well as local newspaper articles and individual meetings. Emphasis is on proper wood burning techniques. 2.0 Food and Consumer Safety An active Food and Consumer Safety Program operated by the Butte-Silver Bow Public Health Department provides education, training, inspections, and enforcement of rules and regulations for licensed facilities in order to prevent food borne illness and other diseases. This program is divided into two sections: 1. Retail food service – consists of inspections, education, and enforcement of retail food service establishments, mobile food service establishments, and temporary food service establishments; and 2. Consumer safety – consists of inspections, education, and enforcement of day care centers, public pools/spas, public accommodations, group homes, and trailer courts/campgrounds. Over 500 inspections are completed in any given year. Manager training and education of food service employees are important factors in the protection of public health. 3.0 Wastewater The Butte-Silver Bow County Health Department administers a program designed to review, permit, and enforce rules and regulations pertaining to disposal of wastewater in areas not serviced by the municipal sewer system (typically known as septic tanks and drain fields). Most of these areas receive their drinking water from private drinking water wells. Proper location, design, and installation of these systems help to ensure that drinking water from individual wells does not become unfit to drink. Additionally, all subdivisions requiring sewer and water are reviewed through this program to make sure they meet all applicable state ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐30 I P a g e rules and regulation. The program licenses installers who construct on-site wastewater systems; they must pass a test to ensure they have the knowledge and experience to properly install these systems. 4.0 Superfund Related Factors Butte’s rich mining history has resulted in significant environmental degradation of soils, surface and groundwater, and attic dust contamination. The area was designated a Superfund site by the EPA in 1983. The Butte area and Clark Fork River Basin together comprise the largest Superfund site in the United States. Many cleanup measures have been completed and several more are being implemented in Operable Units (OU) in the area. These include Butte Mine Flooding (BMFOU), Streamside Tailings (SSTOU), and the Butte Priority Soils Operable Units (BPSOU). Two major programs are administered through the Butte-Silver Bow County Health Department’s Environmental Health Division in the BPSOU. Program elements are designed to protect public health and the environment based on contaminants of concern (COC’s) identified by the EPA which include lead, arsenic, and mercury. An emphasis is placed on children six years of age or younger and pregnant mothers concerning lead exposure. The entire population can be affected by arsenic and mercury; therefore testing occurs throughout the BPSOU and adjacent areas. 1. Residential Metals Program – This program is designed to prevent exposure to the general public in the Butte Priority Soils Operable Unit through sampling of residential soils, indoor dust, attic dust, and paint. If sampling results show elevated levels of lead, arsenic, or mercury, the program has the ability to abate the property. Also, if the property owner is going to do any remodeling, the property will be sampled. If results show elevated levels of COC’s, the property will be abated. This part of the program addresses attic dust. In addition, program officials work closely with other BSB Departments associated with Superfund to ensure abatements are protected (i.e. storm water controls). a. The Women and Infant Children Program (WIC) at the health department provides blood lead testing for children six years of age or under. If an elevated blood level is found in a child (EBL), that property receives first priority for sampling and potential abatement if the lead source is identified. Since the inception of the program, elevated blood lead levels for young children have been reduced to less than ½ of 1% which is well below the national average of approximately Education and proper nutrition information is provided to all mothers of young children to help keep them safe from potential lead sources. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐31 I P a g e b. An extensive data base is kept which tracks properties that are sampled and abated as well as tracking children with an elevated blood level (EBL) to ensure their lead levels are below the standard. Mapping of these properties is done is conjunction with the BSB GIS Department.  1,658 properties have been sampled to date  844 lead-based paint inspections have been done  429 indoor dust vacuum samples have been done  522 attics have been sampled  396 yard abatements have been completed  118 attic dust abatements have been completed  32 interior dust cleanings have been done  149 lead-based paint abatements have been completed c. Education and community outreach are also incorporated into the program. These efforts inform the general public as to the potential health and environmental concerns as well as program elements available to them to abate potential health concerns. 2. Water Quality District – This program was established in 1994 to help improve, enhance, and protect surface and groundwater, not only in the designated Superfund OU’s, but county wide. a. One of the elements associated with the protection of groundwater sources and public health is Controlled Groundwater Areas (CGWA). These are put in place to protect the general public from drilling drinking water wells in areas known to have contaminated groundwater. Drinking water wells are not allowed in these areas. If previous drinking water wells exist in these areas, they are tested for heavy metals annually. 3. Health Studies – Currently, a PhD candidate at Montana Tech is doing an exhaustive study on morbidity and mortality rates in Butte. She is gathering records from the late 1890’s to current and doing a statistical analysis comparing results to the State of Montana and national averages. The final conclusion to the report will show what diseases are more prevalent in our area and where further study needs to be done. 4. Funding for the entire program (Residential Metals and Water Quality District) is through Atlantic Richfield, a Potentially Responsible Party (PRP) for Superfund in the area. No tax payer money is used for the program. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐32 I P a g e V. HEALTH INDICATORS 1.0 Overview This section explores the general health of the County population and includes data about mental health. General health data for Butte-Silver Bow County that is presented in Table 15 was derived from three sources. The first is the Behavioral Risk Factor Surveillance System which is a state-based system of health surveys that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. was established in 1984 by the Centers for Disease Control and Prevention (CDC); currently data are collected in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. More than 350,000 adults are interviewed each year, making the the largest telephone health survey in the world. States use data to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs. Many states also use data to support health-related legislative efforts. The data from this system and presented below is from the 2008 survey for which 177 either metropolitan or micropolitan statistical areas participated. A set of 28 factors from the for Silver Bow County were reviewed. For the purposes of comparing Butte-Silver Bow survey results to the greater pool of survey participants, low figures, high figures and medians are presented for each factor in addition to the Butte-Silver Bow result. In general, a higher percentage is a negative indication. With regard to physical activity, immunizations and access to health care, the higher percentage is a positive indication. Key findings from the data include the following.  Butte-Silver Bow County had negative indications in 21 of 28 factors; this means it scored higher than the median with regard to percentage of the population engaged in unhealthy behaviors and, in some cases, lower than the median with regard to behaviors assumed to be healthy.  Butte-Silver Bow County ranked particularly high in the percentage of adults that:  Have had all teeth extracted (7/177)  Have had any permanent teeth extracted (6/177)  Are overweight (2/177)  Are current smokers (6/177)  Smoke everyday (11/177)  Have been told have coronary heart disease (9/177)  The county was below the median with regard to the following: ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐33 I P a g e  Percentage of adults 50 years of age and older who have had colorectal screenings  Percentage of adults 18-64 who have any kind of health coverage (insurance)  Percentage of men 40 years of age and older who have had a PSA test in the last 2 years  Percentage of adults who have visited a dentist or dental clinic in the last year  Percentage of adults who participated in any physical activity in the past month  Butte-Silver Bow had positive indications (ranked above the median) with regard to the following the  Percentage of women 18 and over who have had mammograms in the last three years,  Percentage of adults that have never smoked (4/177)  Percentage of adults how have ever had a pneumonia vaccination  Percentage of adults who have had a flu vaccination within the past year The second source of data for the health indicators provided here is the 2009 Silver Bow County Health Profile. The Montana Department of Public Health and Human Services publishes a profile for every county in the state which relies upon data provided by the Census Bureau, the Montana Department of Labor and Industry, the Bureau of Economic Analysis, and Mountain Pacific Quality Health Foundation. Data from this source is indicated in the table below by an asterisk. Notable findings emanating from the profile include the following:  The leading cause of death in Butte-Silver Bow County is heart disease; the associated county death rate of 256.8 per 100,000 population, far exceeds the state death rate of 198.3 per 100,000 population  The suicide rate at 27.5 per 100,000 population exceeds the state rate of 20.3 per 100,000 (Montana consistently ranks in the top five states in the nation with regard to the suicide rate)  The percent of mothers who smoke during pregnancy is significantly higher than the state—28% compared with 18%  The unintentional injury death rate (non-motor vehicle) far exceeds the state rate—84.3 per 100,000 population compared with 61 per 100,000 population Finally, some health indicators related to access came from a 2008 community survey conducted by the Butte Community Health Center. The survey distinguishes results by Census Tracts and asked a series of questions regarding access to health care. Key findings from the survey include the following: ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐34 I P a g e  19% of households responding indicated they did not have a regular medical provider; of those, 56% indicated it was because they either had no health insurance or could not afford a provider  The percentage of households indicating they had no regular provider was highest in the higher poverty Census Tracts ( one and two)  14% of responding households indicated they had no form of health insurance (correlates with Census figure regarding health insurance)  23% of households responding indicated they did not have a regular dentist; the figure was significantly higher in Census Tract One the highest poverty Tract in the County. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐35 I P a g e 2.0 Data Table Table 15 KEY INDICATORS OF PUBLIC HEALTH HIGH LOW MEDIAN BUTTE‐SILVER BOW HEALTH BEHAVIORS Alcohol Consumption % of Adults who have had at least one drink within past 30 days 70.1 8.6 58.4 55.5 % Heavy Drinkers (males-more than 2 drinks/day; females-more than one drink per day 9.8 0.6 4.2 5.2 % Binge Drinkers (males-5 or more drinks on one occasion; females-4 or more drinks on one occasion) 25.1 2.9 16.5 15.2 Overweight/Obesity % Overweight (bmi 25.0 - 29.9) 45.7 31.2 36.4 43.4 % Obese (bmi 30.0 - 99.8) 38.7 14.8 26.3 19.5 Physical Activity % Participated in any physical activity in past month 87.7 59.9 75.95 75.3 Tobacco Use % Adults who are current smokers 30.9 4.9 18.4 26.1 % Adults who smoke everyday 23.9 4.2 13.6 18.8 % Mothers who smoked during pregnancy* 18 (Montana) 28 HEALTH STATUS Perceived Health % General Health is Poor 9.3 1.5 3.7 5 % General Health is Excellent 30.4 12.3 22 20.8 Disability % Adults who are limited in any activities because of physical, mental or emotional problems 32.6 12.8 20.2 25.6 % Adults with health problems that require use of special equipment 12.3 2.9 6.95 9.9 Men's Health % Men aged 40+ who have had a PSA test within the past 2 years 70.1 38.9 56.1 52.9 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐36 I P a g e KEY INDICATORS OF PUBLIC HEALTH Continued HIGH LOW MEDIAN BUTTE‐SILVER BOW HEALTH CARE ACCESS Women's Health % Women aged 18+ who have had a pap test within past 3 years 93.2 65.7 84.25 86.6 % Women 40+ who have had a mammogram within past 2 years 88 61.1 77.5 74.5 Colorectal Cancer Screening % Adults aged 50+ who have ever had a sigmoidoscopy or colonoscopy 77.9 44.7 64 57.2 % Adults aged 50+ who have had a blood stool test within past 2 years 50.7 7.1 22.1 19.8 Immunizations % Adults 65+ who have ever had pneumonia vaccination 82.4 45.6 67.9 70 % Adults 65+ who have had flu vaccination within past year 82.4 52.1 72.1 72.1 Health Insurance % Adults aged 18-64 who have any kind of health coverage 96.6 53.6 84.65 79.7 Percent of population (under 65) without health insurance* 19 (Montana) 14 Prenatal Care Percent beginning care in first trimester* 65 (Montana) 67 Percent receiving adequate care* 76 (Montana) 63 Access to Care Givers (Community Health Center Survey) % of households that do not have a regular medical provider 19 % of households that do not have a regular dentist 23 HEALTH OUTCOMES Asthma % Adults who have been told they currently have asthma 13.2 3.6 8.8 11 % Adults who have ever been told they have asthma 19.9 6 13.5 16.2 Cancer Cancer incidence rate (diagnosis per 100,000)* 455.5 (Montana) 321.9 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐37 I P a g e KEY INDICATORS OF PUBLIC HEALTH Continued HIGH LOW MEDIAN BUTTE‐SILVER BOW HEALTH OUTCOMES CONTINUED Cardiovascular Disease % Ever been told they had angina or coronary heart disease 9 2 4.2 6.1 % Ever been told they had a stroke 6.3 0.5 2.5 3.8 % Ever been told they had a heart attack 7.4 1.7 4.1 6.2 Heart disease death rate (leading cause of death)* 198.3 (per 100,000)-Montana 363.5 (per 100,000)-Montana Chlamydia Reported cases per 100,000* 285.3 (Montana) 257.8 Diabetes % Ever been told by a doctor they have diabetes 16.7 2.8 8 8 Infant Mortality Deaths per 1,000 live births* 6.1 (Montana) 4.7 Low Birth Weight Percent of infants born at low birth weight (below 5lbs. 8 oz.)* 7 (Montana) 8 Oral Health % Adults that have had any permanent teeth extracted 62.9 26.5 44.2 56 % Visited the dentist or dental clinic within the past year for any reason 42.7 17.9 29.5 28.2 % Adults aged 65+ who have all natural teeth extracted 36.3 5.2 16.9 24.3 Suicide Suicide rate per 100,000* 20.3 (Montana) 27.5 Unintentional Injury Death Rate Motor Vehicle per 100,000* 25.5 (Montana) 21.4 Non-Motor Vehicle per 100,000* 6 (Montana) 84.3 Percent motor vehicle crashes involving alcohol* 6 (Montana) 10 ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER ONE: INDICATORS OF PUBLIC HEALTH 1‐38 I P a g e 3.0 Mental Health According to the 2000 Decennial Census, 14% (441) of disabled people in the county had a mental illness; this translates into 1.3% of the overall population. However, the number of people being served by the Western Montana Mental Health Center indicates the figure is much higher. In 1997, the Center served 542 people (1.5% of the 1997 estimated population); that number grew to 1,421 in 2006 (4.3% of the 2006 estimated population)40. This would indicate a 162% increase in the number of people in the county with a diagnosed mental illness. This information combined with the extraordinarily high incidence of Severe Emotional Disturbance (11%-13%) in children indicates an increased need for community-based mental health services for both children and adults. The prevalence of mental illness, combined with a high rate of poverty, particularly among senior citizens, and a cultural acceptance of substance abuse create a higher than normal risk for suicide. In Butte-Silver Bow, 65% of tenth grade students surveyed in 2005 believed their parents had favorable attitudes toward alcohol use. Local hospital officials describe a high number of people coming to their emergency room for detoxification and an inordinately high number of babies born in the hospital with fetal alcohol 40 Western Montana Mental Health Center, 2006 41 2004 Environmental Health Assessment, Butte‐Silver Bow County ---PAGE BREAK--- CHAPTER TWO ANALYSIS OF GAPS IN HEALTH-RELATED PROGRAMS & SERVICES ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 1 I P a g e INTRODUCTION The following analysis was performed as part of an overall health needs assessment for Butte- Silver Bow County. The analysis represents stage two of the needs assessment process and is intended to assess gaps that exist in services and programs to address key community health problems. Key health problems were identified during the summer of 2010 by analyzing county level data related to demographic, social and population health behaviors and trends. Information contained in this document was taken from a number of sources including local service directories and local needs assessments conducted by local government and non-profit organizations. It is important to note that the Butte-Silver Bow Growth Policy Update of 2008 that included a look at existing services and gaps related to public health was used in this analysis. For data related specifically to medical providers, the 2010 Net Physician Need report for the Butte area that was provided through Thomson-Reuters—an international research firm with expertise in healthcare data—was used as were the 2010 Montana Medical Association (MMA) Directory, the Blue Cross/Blue Shield of Montana Provider list and the 2010-2011 Qwest Directory. Medical staff from St. James Healthcare and the Butte Community Health Center provided essential review of the medical provider list and gaps in medical services. The document is organized in a way that generally corresponds with the key Indicators of public health contained in Chapter One of this document. Therefore this chapter presents an analysis of gaps related to key population factors, key socioeconomic factors, key factors related to the physical environment, social and behavioral factors and overall health factors, all as they relate to matters of public health. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 2 I P a g e 1.0 KEY POPULATION FACTOR 1.1 SERVICES FOR SENIOR CITIZENS Perhaps the most significant population factor facing Butte-Silver Bow County today and into the future, is the increasing proportion of the population made up of people who are 65 years of age and older. The median age in the county reached 41.6 years in 2008, up from 38.9 in 2000. Currently, there are an approximate 5,700 senior citizens in the county; that number is projected to reach nearly 9,000 by 2025, an increase of 58% or over 3,000 people. Today, senior citizens comprise 16.5% of the county population; by 2025, they will comprise 25%. Although the proportion of seniors is higher in the county than it is nationally, the projected increase is associated with the “baby boom” and will impact the entire nation. This phenomenon will significantly increase the number of people needing health related services, but this demographic group also requires more intense medical services that are often provided by geriatric specialists or family/general practice providers with particular knowledge of and experience with geriatric health issues. Additionally, aging “baby boomers” will contribute hugely to the prevalence of chronic illness into the future; today, approximately two-thirds of people with a chronic illness are over the age of 65. As this cohort grows, so will the incidence of chronic illness. Southwest Montana has an even greater proportion of older people than the nation. Thus, this trend is likely to be more intensely experienced here. Primary care physicians, including those in family practice, internal medicine, pediatrics and OB-GYM physicians, who are at the forefront of managing chronic illness, are already in short supply. With a growing senior population, this shortage will become an even more pressing healthcare matter if not addressed. “Baby boomers”, as a group have adapted life styles that may call for new approaches to service delivery and community planning. For example, they tend to prefer living closer to amenities and aging in their homes rather than moving to apartment complexes in peripheral areas of cities or into assisted living communities. Planning for the provision of services to senior citizens who have different living preferences is a significant and pressing need. For example, home health services will play a bigger role in service delivery for this population. In Butte-Silver Bow, a high proportion of senior citizens have low-incomes; in 2000, over half had annual incomes below $15,000. Provision of services to low-income seniors is more challenging as it adds an “affordability” layer to the equation and often requires special grants and pay sources to create access to services. An analysis of current services for the aging population reveals some important gaps including the following:  There are currently no medical providers specializing in geriatric medicine in Butte-Silver Bow County  There is currently a shortage of primary care physicians for the county population ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 3 I P a g e  There are currently 3 licensed home health agencies; these services require private pay and are not affordable for many seniors; many seniors require what is considered “unskilled” assistance in their homes, assistance that is essential but not reimbursable through current pay sources and not affordable for many  There are not adequate transit services that pick people up at their door and deliver them directly to their destination (door-to-door transit services)  There are currently no businesses or agencies specializing in assisting seniors with adapting their homes for “aging in place”; this is of particular importance to low-income seniors  While there are 401 beds in long-term/skilled nursing facilities, there is a shortage of long-term care services and/or an unwillingness among existing facilities to accept patients with mental health, behavioral problems (including dementia) and alcohol/drug addictions  While the Butte Community Health Center provides care management services to its patients, there is a lack of care management for the general senior population who need assistance navigating the complex health care system  For some seniors who have no family or other supports, there is a lack of assistance in the community with financial management With significant growth expected to occur in this age cohort, expansion will need to occur in the following:  Growth in the 65 and over age cohort will call for more primary care physicians to manage chronic illnesses  Growth in seniors will require more oral health services, particularly those who provide services affordably to low-income seniors.  There are currently 401 beds in 4 long-term/skilled nursing facilities to serve the current population. If this model prevails in the industry, an expansion in the number of beds available for the aging population will likely have to expand.  There are currently 3 hospice organizations serving the county; a new agency came on line during the period in which this report was written; this service may also require expansion as the senior population grows  There are currently 3 licensed home health providers in the county; the Butte-Silver Bow Health Department is the only agency providing these services on a sliding fee basis. Growth in the senior population will call for expansion of affordable home health services.  There are 504 dedicated senior citizen housing units, all apartment-style; only 66 units are at Front Street or above (Rosalie Manor); there will be a need for more housing above Front Street that allows seniors to live independently near medical services and other amenities  Services that help senior citizens make adaptations to their homes thereby allowing them to age in place will be needed, particularly services that are affordable to low-income senior citizens ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 4 I P a g e  The Belmont Senior Center provides 1,200 rides per month to senior citizens; the service transports people to lunch at the Center, to medical appointments and to shopping destinations two days per week; there is a current need for expanded transit services for seniors and the services will need to expand further to accommodate growth  The Belmont Senior Center currently offers congregate lunches five days each week and delivers meals to senior citizens Monday through Friday and the Butte Emergency Food Bank provides one free box of food per household each month; there will be a need to expand theses nutrition services to accommodate growth The following chart illustrates the connection between the key population findings related to senior citizens, health related needs, current services offered in Silver Bow County and gaps in services. Where medical providers are listed, the information was determined through a cross reference of the 2010 Thomson-Reuters Area Physician Listing and Net Physician Need by Specialty, the 2010 American Medical Association Directory, the Blue Cross/Blue Shield of Montana Provider Network and the 2010/2011 Qwest Directory. St. James Healthcare and Community Health Center staff was also assisted with determining gaps in medical services.  Aging Population; 25% of population will be 65 or older by 2025; the number of seniors is expected to increase to approximately 8,933 ‐‐an increase of over 3,000 seniors  Aging “baby boomers” have a preference for aging in place and services delivered in the home  More than half of senior citizens are low‐income; 55% of people over 65 in Butte‐Silver Bow County had incomes of less than $15,000 in 2000  In America today, approximately two‐ thirds of people with chronic illness are 65 or over; this will increase as baby boomers age  There are currently no physicians specializing in geriatric medicine in the County  There is 1 half‐time practicing urologist in the County  There are no practicing podiatrists in the County  CHC provides oral health screens and education in nursing homes and once per month at the Belmont Senior Center FINDINGS EXISTING SERVICES NEEDS Geriatric Health Care Services  Primary care is essential to the management of chronic illness which is more prevalent among older people; there is a national and local shortage of primary care givers; there are currently 23 FTE primary care providers which falls short of the standard population to provider ratio by 15 Primary Care Providers  There are currently 3 licensed home health agencies in the County; BSB Health Dept. provides skilled nursing and therapy services to homebound individuals on a sliding fee; average 25‐40 patients  There are currently no resources to address the need for “unskilled” home health services that have no pay source for the individual  There are currently 3 licensed hospice organizations providing services in the County Home Health and Hospice Services Skilled Nursing and Long‐term Care  There are currently 4 skilled nursing/extended care facilities in the County with a total of 401 beds; many will not accept patients with mental health/behavioral problems or chemical addictions  The medical campus and the majority of medical services are located at or above Front Street  There are 504 dedicated senior housing rental units in the county; of these, 18 are Alzheimer‐ dedicated units; 123 are assisted living units; 60 are supported units  There are 66 rental units for seniors at or above Front St.  24 new dedicated senior rental units are slated for construction on Continental Drive, a long distance from the medical campus Housing for all incomes close to medical services and amenities GAPS Current Needs MEDICAL PROVIDERS SPECIALIZING IN GERIATRIC MEDICINE MORE AFFORDABLE HOME HEALTH SERVICES ADEQUATE DOOR‐ TO‐ DOOR TYPE TRANSIT SERVICES SERVICES TO ADAPT HOMES FOR AGING IN PLACE, PARTICULARLY FOR LOW‐INCOME SENIORS MORE PRIMARY CARE PROVIDERS LONG‐TERM CARE BEDS FOR SENIORS WITH DIMENTIA, MENTAL ILLNESS, SUBSTANCE ABUSE PROBLEMS EXPANDED “PAYEE” AND FINANCIAL PLANNING AND MANAGEMENT SERVICES ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 5 I P a g e Services for Senior Citizens continued….  Aging Population; 25% of population will be 65 or older by 2025; the number of seniors is expected to increase to approximately 8,933 ‐‐an increase of over 3,000 seniors  Aging “baby boomers” have a preference for aging in place and services delivered in the home  More than half of senior citizens are low‐income; 55% of people over 65 in Butte‐Silver Bow County had incomes of less than $15,000 in 2000  In America today, approximately two‐ thirds of people with chronic illness are 65 or over; this will increase as baby boomers age  A January, 2008 spot survey of seniors in local low‐ income housing showed that 66% had no dental care in the past year; 31% had no dental care in the past 10 years  The Belmont Center currently provides meals on wheels and congregate meals Monday through Friday  The Butte Emergency Food Bank provides free food boxes; 1/household/month Nutrition Services EXISTING SERVICES NEEDS FINDINGS  The Senior Companion Program matches seniors with a companion to provide one‐on‐one social interaction; there is a need for more  The Belmont Senior Center provides a variety of activities for seniors  AWARE provides a gathering place at St. Joseph’s church for seniors with developmental disabilities  Senior housing complexes provide social activities for residents of the facilities  Many older women participate in numerous “Red Hat Society” groups for social purposes Social Opportunities  There is currently no programming for lower‐income seniors to adapt homes  There are no businesses currently providing this service to any income groups  Most housing close to health care campus is older and not easily adapted for aging in place; average age of homes in uptown area is 1939; over half of units are in substandard condition Housing for all incomes that allows for aging in place  The Belmont Senior Center provides an average of 1,200 bus rides per month to seniors; they provide transportation for congregate meals Monday through Friday, transit to medical appointments Monday through Thursday for a minimal fee and transit for shopping two days per week.  Senior living communities provide transportation to appointments and other engagements Transit services and pedestrian systems connecting housing to services and amenities  The Belmont Center currently provides free financial management assistance to seniors; there is a need for “payee” services to assist the elderly with bill paying and other financial matters  There are private financial planners in the county who assist seniors with financial planning Financial Planning, Management  There are 123 assisted living units in the County and 60 supportive units for low‐income seniors  Homeward Bound provides transitional housing for homeless people for up to 24 months; the program is not specific to seniors, but can coordinate services on their behalf through case management  AWARE provides housing for developmentally disabled adults with support services in group home setting. Assisted Living, Transitional Housing Future Needs MORE AFFORDBLE ORAL HEALTH SERVICES MORE PRIMARY CARE PROVIDERS TO ACCOMMODATE GROWTH SERVICES TO ADAPT HOMES FOR AGING IN PLACE HOUSING NEAR THE HEALTHCARE CAMPUS AND AMENITIES THAT IS AFFORDABLE AND APPROPRIATE FOR SENORS GAPS EXPANSION OF LONG‐ TERM, SKILLED NURSING CARE AND HOSPICE SERVICES TO ACCOMMODATE GROWTH IN SENIOR POPULATION EXPANED TRANSIT SERVICES TO ACCOMMODATE GROWTH EXPANDED MEAL SERVICES TO ACCMMODATE GROWTH EXPANSION OF LONG‐ TERM CARE SERVICES FOR SENIORS WITH DEMENTIA AND MENTAL ILLNESS EXPANDED SENIOR COMPANION SERVICES  There are currently inadequate services to serve elderly people with chemical dependency issues; they often cannot be placed in nursing homes due to behavioral problems  There are inadequate advocacy services to address elder abuse Advocacy and Special Needs ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 6 I P a g e 2.0 KEY SOCIOECONOMIC FACTORS 2.1 SERVICES AND INITIATIVES TO ADDRESS POVERTY AND LOW-INCOME NEEDS A significant proportion of Butte-Silver Bow County household have low annual incomes. In fact, the proportion is higher in Butte-Silver Bow County than in the nation as a whole. An income analysis of households from the 2000 Census showed that 42% of households in the County had incomes below $25,000 compared with only 29% for the nation and 38% for the state of Montana. Thirty-seven percent (37%) of the county population is at or below 200% of the federal poverty line, qualifying them for low-income assistance programs like Low Income Energy Assistance (LIEAP) and a sliding fee at the Community Health Center. Despite the efforts of numerous public and private, non-profit organizations to ensure people without resources have access to basic necessities, poverty persists in Butte-Silver Bow County. Poverty, as it is defined in the U.S., means that one is so income deficient as to be unable to purchase essential goods and services. The federal government establishes an annual income amount believed necessary for basic subsistence for each household size. This is known as the federal poverty level and the U.S. Census Bureau determines how many households subsist below that level or the “poverty rate”. In Butte-Silver Bow, the poverty rate, at 15.8%, is higher than both the national and state rates and has risen almost a full percentage point since 2000. Further, 20% of children in Butte-Silver Bow are living in poverty; this rate has increased a full percentage point since 2000. Butte-Silver Bow County, through state, federal and private, non-profit efforts, has an array of services to assist people with inadequate resources. There are a number of programs to assist with housing, nutrition, health care, transportation, clothing and employment readiness. The Belmont Center, the Butte Emergency Food Bank, Human Resources Council, School District #1 and the state of Montana through the Supplemental Nutrition Assistance Program (SNAP) work to ensure people, from children to senior citizens, have adequate nutrition. The Butte Community Health Center and St. James Healthcare provide health care services either through a sliding fee or through charity care. Housing is made safe, warm and affordable through programs offered by Habitat for Humanity and the National Affordable Housing Network, Human Resources Council, the Public Housing Authority of Butte, the Legion Oasis, the Highland View Manor and Columbus Plaza, the Silver Bow Village and various other providers of low-income housing. Butte-Silver Bow County provides a public bus system five days per week; the Human Resources Council can, on a limited basis, assist people with the purchase of bus passes. Career Futures, Inc. and the Butte Workforce Center can assist people with career exploration, job search as well as training and job readiness. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 7 I P a g e Programs to assist people with low or no income are most often subsidized or fully funded by government programs and therefore, depend on the availability of public funds. In some cases, funding is not adequate to meet community needs. For this reason and others, there are gaps in needed services. The “gaps analysis” revealed the following current gaps in services for the low-income population.  There is a need for more primary care physicians to serve the low-income population  There is a need for more affordable housing units as illustrated by long wait lists for public housing and Section 8 rental assistance  There is a need for programming and funding to rehabilitate housing in much of the urban core above Front Street  There is a need for more funding to assist with home heating  There is a need for nutrition programs to extend to weekends as current services are offered only Monday through Friday  There is a need to provide food that is higher in nutritional value at the Food Bank, particularly for people who are diabetic or have other health problems The following chart illustrates the gaps as they related to needs and key data findings related to poverty and low-income needs. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 8 I P a g e MORE AFFORDABLE, SAFE HOUSING UNITS PROGRAMS AND FUNDING TO ASSIST WITH HOUSING REHABILITATION PROGRAM AT THE FOOD BANK TO ADDRESS THE NUTRITIONAL VALUE OF FOOD BEING GIVEN AWAY NUTRITION SERVICES ON WEEK ENDS, BOTH FOR SENIORS AND CHILDREN DURING THE SUMMER AT LEAST 2.83 PRIMARY CARE PHYSICANS EXPANSION OF LOW INCOME ENERGY ASSISTANCE TO MORE HOUSEHOLDS  15.8% of the population lives below the federal poverty line; 20% of children are living in poverty  37% of the population has incomes at or below 200% of the federal poverty line  In 2000, the proportion of households with incomes below $25,000 (42%) was significantly higher than the national proportion (29%)  44% of households with rent are paying more than 30% of income for rent—a cost burden  Most of the non‐ federally assisted rental units that are affordable to low‐income households are located in Census Tract One where over half of all housing units are substandard FINDINGS  The Butte Community Health Center provides access to full medical/dental services on a sliding fee basis; it serves 13,000 low‐ income people per year; the county is short 2.83 primary care physicians to serve the population  BSB Health Department provides reproductive health care, maternal child health, immunizations, detention center health care and home health services on a sliding fee basis  St. James Health Care; 100‐bed hospital, provides charity care on a limited basis for people with no insurance and lack of ability to pay; St. James has the highest rate of charity care among major hospitals in the state EXISTING SERVICES Health/Dental services affordable for low‐income people NEEDS  There are currently 916 housing units in federally assisted housing projects in the County; 256 are senior citizen‐dedicated units  The major provider of federally assisted housing is the Public Housing Authority of Butte (PHA); there are currently 409 households on the wait list for their units  HRC and the PHA make available 363 Section 8 rental assistance vouchers; there are currently 238 households on the wait list for 342 HRC vouchers and 162 on the wait list for 21 PHA vouchers  Habitat for Humanity and the National Affordable Housing Network build homes in partnership with low‐income people; 45 homes have been constructed in the Central Butte area  The County has undertaken some limited rehab work in Central Butte; currently no funding for further work  HRC assists over 2,500 households in the county per year with heat bills through LIEAP and Energy Share; many more households are eligible  HRC is weatherizing over 500 homes in the County, a significant increase; program is adequate to meet needs over the next 5 years Safe, warm, affordable housing  The federal Supplemental Nutrition Assistance Program (SNAP) provides food assistance (4,589 people in 2010)  The Food Bank provides one appropriately sized box of food per household per month; an average of 1,447 orders were filled per month in 2010; able to meet demand, but does not currently focus on the nutritional value of food in the boxes  The Belmont Center provides congregate and delivered meals 5 days per week to senior citizens  School District #1 provides free or reduced cost breakfast and lunch during the school year  HRC provides free lunch for children Monday‐Friday during summer months  WIC provides supplemental foods and nutrition education for low‐ income pregnant, breastfeeding, and non‐breastfeeding postpartum women, infants and children up to age five at nutritional risk Food/Nutrition Employment, Training  Career Futures provides job training, job readiness, job search and career exploration services through a variety of programs (WoRC, SNAP, WIA, Carl Perkins, Displaced Homemaker)  Workforce Center posts job openings, assists with resumes and job applications  Butte‐Silver Bow Transit system provides public bus rides  HRC provides limited assistance with bus passes  4 thrift shops provide clothing for low‐income people Transportation Clothing GAPS Current Needs ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 9 I P a g e 2.2 INITIATIVES TO ADDRESS HOUSING, HIGH POVERTY NEIGHBORHOODS AND DECAY There is concern among providers of human services that the problem of poverty in Butte-Silver Bow County has become intergenerational and intractable. After observing this trend over the last 10 years, the local Community Action Agency (Human Resources Council) has undertaken a new initiative to address the characteristics of poverty that persist and are passed down through generations. This initiative, therefore, not only seeks to improve living conditions like housing and the availability of basic necessities, but to address manifestations of poverty like dependence, apathy and underachievement. The new initiative is a comprehensive neighborhood-based approach to changing poverty that improves physical conditions, but also provides important support services that are delivered through a neighborhood center model. It also focuses on de-concentrating poverty by developing housing in such a way as to create mixed income neighborhoods. This approach requires strong collaboration among existing providers of services. By changing the neighborhood environment, the hope is to change the mindset that keeps people from achieving success and exiting poverty. A pilot project is currently underway in the Emma Park area of Central Butte. The local Habitat for Humanity organization and the National Affordable Housing Network have an initiative to build low-income housing in what is referred to as “Central Butte” in which it has built 45 homes over the last several years and has intentions of beginning a similar initiative on Butte’s north side. The approach addresses affordable housing only. An analysis of existing initiatives and programs reveals a series of gaps that should be filled if poverty is to be overcome in the county. The gaps analysis yielded the following needs.  There is a need for more homeownership opportunities for low-income people  There is a need for revitalization programs in neighborhoods targeted in the 2006 Housing Plan to address poverty and blight  There is a need to focus the delivery of services in a neighborhood-based model to include health care, social support, financial counseling, youth-related programs and housing services  There is a need to engage in neighborhood-based capital improvements planning in order to identify and make improvements to decayed and broken infrastructure The following chart illustrates the identified gaps within the context of identified needs and existing initiatives and services. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 10 I P a g e GAPS NEIGHBORHOOD REVITALIZATION PROGRAMS IN TARGET NEIGHBORHOODS THAT ENCOURAGE MIXED INCOME ENVIRONMENTS NEIGHBORHOOD BASED CAPITAL IMPROVEMENTS PLANNING FOR MAKING IMPROVEMENTS TO INFRASTRUCTURE Current Needs NEIGHBORHOOD‐ BASED SERVICES INCLUDING HOUSING COUNSELING, HEALTH CARE AND HOME REHAB ASSISTANCE MORE HOMEOWNERSHIP OPPORTUNITIES FOR LOW‐INCOME PEOPLE  HRC is currently undertaking a pilot neighborhood redevelopment project in the highest poverty area of the county; focuses on importing middle income households while preserving housing for low‐income citizens  Habitat for Humanity and the National Affordable Housing Network develop targeted low‐income housing in the Central Butte area FINDINGS  Poverty is highly concentrated in neighborhoods within Census Tract One where poverty rates are as high as 60%; the concentration contributes to a continuing cycle of poverty  Over half of people in poverty in SB County reside in Census Tracts one and two where half of housing units are in substandard condition  29.6% of children in 2000 were living in high poverty neighborhoods  Homeownership rates in high poverty neighborhoods are much lower than in the county as a whole  Five neighborhoods were identified in a housing 2006 housing study as needing redevelopment due to poverty and blight Economically diverse neighborhoods  Butte‐Silver Bow County has implemented an infrastructure and housing rehab program on a few blocks of S. Main Street; funding is exhausted at this time  Habitat for Humanity and the National Affordable Housing Network (NAHN) have constructed 45 new homes in the Central Butte area, some in conjunction with sidewalk and lighting improvements; NAHN plans more neighborhood revitalization in an area of Butte’s north side that will be targeted low toward low‐income households  HRC is working in partnership with the Butte‐Silver Bow Office of Community Development on a pilot neighborhood redevelopment project in the Emma Park neighborhood; the project will include construction of a neighborhood center, infrastructure improvements, housing rehab and new construction and the provision of support services to poor and low‐income households  HRC intends to continue its initiative in other Butte neighborhoods, but there is currently no funding for the work  Butte‐Silver Bow County has a community decay ordinance that is enforced by an officer of the County; properties owners in violation of the decay ordinance can be order to clean up their property or be fined NEEDS EXISTING INITIATIVES Safe, livable neighborhoods NEIGHBORHOOD COUNCILS IN HIGH POVERTY NEIGHBORHOODS THAT ENCOURAGE CITIZEN INVOLVMENT AND INVESTMENT IN HEALTHY NEIGHBORHOOD ENVIRONMENTS Neighborhood‐ based programs and services to address effects of poverty  The PHA has a community center for use by residents of the Silver Bow Homes  There are currently no “neighborhood centers” in the county; HRC has plans to build a neighborhood center in the Emma Park neighborhood; services will include LIEAP, Housing/Financial Counseling, Youth services, some health care related services and a carpentry shop; funding is pending  Headwaters RC&D and NAHN collaborate on providing homebuyer education and housing counseling Homeownership Opportunities  Habitat for Humanity and the National Affordable Housing Network build houses in partnership with low‐ income people to create homeownership opportunities; 45 homes have been built in the Central Butte area  HRC provides a very limited homeownership opportunity for families receiving Section 8 assistance; there are currently only 2 families in the program ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 11 I P a g e 2.3 SERVICES TO ADDRESS HOMELESSNESS Homelessness continues in Butte-Silver Bow at a rate similar to 1994 when the first homeless count was conducted. The number of people being served annually at Homeward Bound, a transitional housing program for homeless families and individuals, has remained steady over the past fifteen years. There are a number services designed specifically to address homelessness in the County. The Human Resources Council (HRC) operates the Homeward Bound program which combines housing with case management and support services to help people transition to permanent housing. HRC, in collaboration with the Butte Community Health Center, brings lunches to homeless people at various locations throughout Butte every Monday through Friday. The Butte Community Health Center brings healthcare services to the homeless population by providing three clinics per week at the two major homeless service sites in the county—Homeward Bound and the Butte Rescue Mission. The Butte Rescue Mission provides three meals each day and emergency shelter and the Salvation Army assists the homeless with rent vouchers. The Butte Emergency Food Bank makes food boxes available to this population as well. An analysis of gaps in existing services indicates there is a need for transitional housing specifically to accommodate families. Currently, family accommodations are provided with those for single people. For safety reasons, it is important to provide separate accommodations when children are present. The following chart illustrates this gap.  HRC provides transitional housing for 24 single male and female adults and has 4 units for couples or families; residents make a 3‐ month commitment and receive case management, support services, life skills and help with obtaining permanent housing (Homeward Bound) FINDINGS EXISTING SERVICES  The number of homeless persons persists at between 86 and 96 per year GAPS SEPARATE EMERGENCY SHELTER ACCOMMODATIONS FOR FAMILIES Current Needs A SEPARATE TRANSITIONAL HOUSING FACILITY FOR FAMILIES  HRC provides transitional housing for up to 4 families at one time (Homeward Bound); it is not ideal to house families with single adults  The Butte Rescue Mission provides Emergency Shelter  Salvation Army provides emergency rent vouchers  HRC provides limited emergency rent vouchers The Butte Ministerial Association provides motel vouchers on a limited basis Transitional housing for adults only NEEDS Transitional housing for families Emergency shelter Food  The Butte Rescue Mission provides 3 meals per day  Residents of the Homeward Bound program have 3 meals per day  The Butte Emergency Food Bank provides food boxes for this population Prevention Services  HRC provides temporary rental assistance to indigent adults who are disabled and applying for Social Security Disability (Silver Bow Assistance Program); funding is adequate to meet demand Healthcare Services  CHC brings healthcare to homeless people by provided 3 clinics per week at the 2 major homeless service sites in the county‐‐ Homeward Bound and the Rescue Mission ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 12 I P a g e 3.0 KEY FACTORS RELATED TO THE PHYSICAL ENVIRONMENT 3.1 PROGRAMS TO ADDRESS AIR, WATER AND SOIL QUALITY AND FOOD SAFETY One hundred years of extractive mining in Butte-Silver Bow have left environmental degradation and scars that have necessitated many years of evaluation, planning and remediation. The Butte area and the Clark Fork River Basin comprise the largest Superfund site in the United States. In areas that impact public health, the Butte Silver Bow County Health Department’s Environmental Health Division is charged with helping to ensure public health and the environment are protected. They monitor air quality, drinking water quality, food safety in places where the public consumes food, and exposure to environmental hazards, particularly in homes where children under the age of 6 may be exposed to lead dust in attics and other hazardous substances, particularly arsenic and mercury. Air quality in Butte-Silver Bow County is close to a level of PM-2.5 that violates National Ambient Air Quality Standards. With the shift of people living away from the urban center, increased travel times to work centers has an impact on air quality. However, recent studies have shown that the greatest contribution to the PM (particulate matter) concentrations come from residential wood smoke during the winter months. Other major contributors include ammonium nitrate, automobiles, secondary sulfate, street sand, and diesel exhaust. To this end, encouragement of housing development in the urban cluster along with an enhanced educational effort concerning other air quality issues would support better air quality. The Butte-Silver Bow Health Department provides important services in the areas of air, water and soil quality and food safety. They are currently understaffed in the areas of food safety and water quality. At least one registered sanitarian is required to meet the standard of at least one sanitarian to 280-320 inspections; currently, the ratio is 1:360. A recent report recommends 1.8 – 2 FTE sanitarians to have a truly effective program. The following chart illustrates the needs related to implementing effective environmental programs in Butte- Silver Bow County. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 13 I P a g e  The Butte Silver Bow Health Department completed a Chemical Mass Balance Study to determine major sources of PM‐10 revealed residential wood burning, road dust, and diesel engines to be the major contributors to Butte’s PM‐ 10 problem. A new air quality ordinance and educational program was enacted to address residential wood burning and idling diesel engines, along with a more effective street sweeping and flushing program. Commercial and industrial sources (i.e. Montana Resources, asphalt plants, etc.) are regulated by the State of Montana’s Department of Environmental Quality. With these efforts, Butte has not violated these standards for many years.  Through the Health Department, particulate air quality monitoring occurs daily at the Greely School site FINDINGS NEEDS EXISTING PROGRAMS  Butte‐Silver Bow County is very close to violating PM‐2.5 standards for air quality  More people living further from work and service centers is creating more travel time in cars which contributes to poor air quality  The Butte area is part of the largest Superfund site in the United States  Mining related contaminants of concern are lead, arsenic and mercury  Food & Consumer Safety and Water Quality services are understaffed  The Butte‐Silver Bow Health Department oversees a “Water Quality District”; this program was established in 1994 to help improve, enhance, and protect surface and groundwater county‐wide.  Water Quality District includes the Ground Water Controlled Areas program that precludes drilling of drinking water wells in areas known to have contaminated ground water  The Health Department reviews, permits and enforces rules pertaining to waste water disposal Clean air Clean water Clean soil  The “Residential Metals Program” helps prevent exposure of the general public to hazards in the Butte Priority Soils Operable Unit through sampling of residential soils, indoor dust, attic dust, and paint. If sampling results show elevated levels of lead, arsenic, or mercury, the program has the ability to abate the property. If a property owner planning any remodeling, the property will be sampled. If results show elevated levels of COC’s, the property will be abated. This part of the program addresses attic dust. In addition, the program works closely with other BSB Departments associated with Superfund to make sure that abatements are protected (i.e. storm water controls). Health Monitoring  Through WIC, blood lead testing for children 6 years of age or under is available. If an elevated blood level is found in a child (EBL), the associated property receives first priority for sampling and potential abatement if the lead source is identified. Since the program’s inception, elevated blood lead levels for young children have been reduced to less than ½ of well below the national average. Food Safety  The Health Department provides inspections, education, and enforcement of retail food service establishments, mobile food service establishments, and temporary food service establishments as well as day care centers, public pools/spas, public accommodations, group homes, and trailer courts/campgrounds; 500 inspections per year are completed. GAPS MORE PUBLIC EDUCATION ABOUT THE IMPACT OF auto EMISSIONS ON AIR QUALITY Current Needs ENCOURAGEMENT OF HOUSING DEVELOPMENT CLOSE TO WORK AND SERVICE CENTERS NEED FOR AT LEAST 1 FULL‐TIME POSITION WITHIN THE WATER QUALITY PROGRAM TO EXPAND INTO IMPORTANT AREAS OF WATER QUALITY OUTSIDE OF SUPERFUND‐RELATED WORK NEED FOR AT LEAST 1 FULL TIME REGISTERED SANITARIAN TO MEET THE MINIMUM STANDARD RATIO OF 1 SANITARIAN TO 280‐320 INSPECTIONS ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 14 I P a g e 4.0 KEY SOCIAL and BEHAVIORAL FACTORS 4.1 PROGRAMS TO ADDRESS CRIME In 2009, Butte-Silver Bow County had the highest crime rate among the seven major counties in Montana. The County consistently has a high rate of domestic violence crime. This phenomenon can be linked to Butte’s history as a mining town. The same social problems are known to have evolved in mining camps. Thus, in addition to the environmental damage left by mining, the community continues to remediate the social damage. The County has a Sheriff and staffed police force as well as a complete justice system. Drug and DUI courts have recently been added to the justice component of the system. There is also a renewed effort to begin Neighborhood Watch programs in the community. The following gaps analysis illustrates key community findings with regard to crime and existing services and programs within the County. Two notable gaps that result include:  The need for more patrol officers  The need to establish Neighborhood Watch programs throughout the county Community policing  Butte‐Silver Bow County has 46 sworn police officers that make up its police force; 36 of these are patrol officers; shifts average 5 patrol officers  The number of officers falls short of the Montana average ratio of sworn officers to population  The Butte‐Silver Bow Police Department has a dedicated Community Liaison Officer who provides assistance with establishing neighborhood watch programs  A neighborhood watch has been established at the Legion Oasis Housing Complex; 2 neighborhoods are in the process of establishing a neighborhood watch FINDINGS NEEDS EXISTING SERVICES GAPS NEIGHBORHOOD WATCH PROGRAMS IN EVERY NEIGHBORHOOD Current Needs MORE POLICE OFFICERS ARE NEEDED  At 4,873 per 100,000 people, Butte‐Silver Bow had the highest crime rate among major counties in Montana in 2009  At 607 per 100,000 people, the County also had the highest rate of crimes related to domestic violence Involved Citizenry  Butte Silver Bow County has 2 presiding District Court Judges  The County has one presiding City Judge  The County has two presiding Justice Court Judges  The County has one coroner  The County has a Youth Court, a Drug Court and a DUI Court  Probation Services are provided through Butte‐Silver Bow County and Community, Counseling and Corrections, Inc. (CCCS, Inc.)  Pre‐release programs are provided by CCCS, Inc. Justice System ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 15 I P a g e 4.2 PROGRAMS AND INITIATIVES TO ADDRESS CHILD WELL BEING There are strong indications that a significant number of children in Butte-Silver Bow are in distress. The prevalence of Severe Emotional Disturbance (SED) is significantly higher in the County than it is nationally and the number of children per 1,000 who have been removed from their homes due to neglect or abuse is also higher than the national rate. This distress is undoubtedly linked to the high risk community environment in which children are developing. A high crime rate, domestic violence, high poverty neighborhoods and norms favorable toward substance abuse are factors that place children at risk for unhealthy development; all of these factors are present in Butte-Silver Bow. In fact, the 2008 Montana Prevention Needs Assessment, a survey of high school students, indicated that nearly 60% of high school seniors were at high risk for problem behaviors and just under half had engaged in binge drinking within two weeks of completing the survey. Low commitment to school and an increased high school drop-out rate among seniors is another indication that children and youth issues require the community’s attention and focus. In order to improve child well-being, it will be necessary to change the environment. There are a number of very important and effective programs and services in place to help children and families in distress. There are also a number of community initiatives that focus on creating a healthier community environment for children. The analysis of services and gaps to address the key findings related to child well-being reveals a number of gaps. They include:  The need for transitional housing for youth exiting foster or institutional care  The need for resources to assist families with children in need of treatment who either have no pay source or have exhausted a pay source and further treatment is necessary  The need to expand neighborhood redevelopment programs that focus on reducing poverty and providing neighborhood-based youth services  The need to create neighborhood-based crime programs in all neighborhoods  The need to for initiatives and programs that keep youth in school and reduce the high school drop- out rate  The need for practitioners in the field of child and to support recovery and treatment.  The need for more local therapeutic in-patient treatment opportunities in order to keep children in their communities and near their support networks. The following chart relates key findings to existing services and illustrates current gaps that need to be addressed by the community. Please note that where there is an asterisk, this indicates that the data sources included the 2010 Thomson-Reuters Net Physician Need by Specialty, the 2010 Montana Medical Association, Blue Cross/Blue Shield and Qwest Directories. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 16 I P a g e GAPS Current Needs FINDINGS  Butte presents a high risk community environment for child development; high crime, domestic violence, poverty and norms favorable toward substance abuse  Over 60% of 12th grade students were at high risk for problems behaviors; Just under half had engaged in binge drinking in 2008  2009 High School drop‐out rate was 25%; 63% of 12th grade students indicated low commitment to school in 2008 survey  11% ‐ 13% of children between 9 and 17 were diagnosed with SED in 2006 compared with the national prevalence rate of 5% ‐ 9%  Nearly one‐third of children in 2000 lived in high poverty neighborhoods  The rate of children removed from homes for abuse or neglect was 13.6 per 1000 in 2009 compared to the national rate of 12.1  4.42% of children in the county were evaluated for sexual abuse at the CHC Child Evaluation Center between 2007 and 2009 EXISTING SERVICES& INITIATIVES  Butte Cares; initiative to reduce substance abuse among youth  Mariah’s Challenge; initiative to end underage drinking through education and provision of scholarships to youth who opt not to abuse alcohol/drugs  Neighborhood Watch; a neighborhood‐based approach to crime prevention; Butte‐ Silver Bow Law Enforcement Department has a crime prevention officer working to initiate watch programs in Butte neighborhoods; 2 neighborhoods are in the process of forming; there is a watch program at the Legion Oasis Housing Complex  HRC Neighborhood Initiative; initiative to create healthier social and physical environments in high poverty neighborhoods  Crime Stoppers; community‐based crime watch and reporting program  School District #1 focus on decreasing high school drop‐ out rate  BSB Health Department provides education in schools about drug use/abuse and is working on initiatives to minimize risk factors and increase protective factors  NAIA; education and prevention program for youth NEEDS Healthier community environment  Child and Family Services; state and federally mandated protective services to children who are abused, neglected or abandoned; 2 social workers in Butte investigate reports and work with families to prevent domestic violence, stay together or reunite and find placements in foster or adoptive homes  A Guardian ad litem can be appointed to act as a child’s legal advocate in cases of neglect or abuse  Safe Space; domestic violence shelter for women and their children  CHC provides sexual abuse prevention and personal safety education in K‐3 elementary classrooms within the public school system Protective and Prevention Services  There are 23 practicing primary care physicians, which includes pediatricians and family/general medicine physicians; 1 pediatric nurse practitioner; 8 family practice nurse practitioners  Pediatric cardiology, urology and neurology services are available once per month and are provided by licensed physicians who travel from elsewhere*  CHC provides the only evidence‐based therapy services for kids experiencing trauma on a sliding fee basis and a child evaluation center in cases of suspected sexual or physical abuse  ACADIA provides residential treatment to children and adolescents with co‐ occurring behavioral, emotional and disorders  Western Montana Mental Health provides case management, community‐based rehabilitation & support and in‐school support for children with SED  AWARE provides clinical, therapeutic, services, case management and community‐based residential services to children with mental & physical disabilities  There are approximately 30 private clinicians who provide therapy services; many do not accept Medicaid  Family Outreach provides free service coordination, education, support and resources to families who have a child with a disability  There are few resources for families with inadequate ability to pay Treatment and Support Services  The Department of Family Services provides social workers who assist children leaving foster care with finding housing and ensuring basic needs are met  AWARE provides support to youth with transition to independence  There is currently no dedicated transitional housing for kids leaving foster care or institutional care  School District #1 provides K‐12 education and an alternative school  HRC‐ Jobs for Montana’s Graduates program; preparatory services for life after high school; includes career selection and skills that lead to success in the work place  HRC‐ Youth Employment & Training Program; work experience, case management, occupational skill development  Head Start; early childhood education to prepare kids 3‐6 for kindergarten  AWARE‐provides Early Head Start education for children under 3 years Transitional Services Education, training TRANSITIONAL HOUSING AND SUPPORT FOR KIDS LEAVING FOSTER OR INSTITUTIONAL CARE FUNDING FOR TREATMENT SERVICES FOR FAMILIES WITH NO PAY SOURCE OR FOR WHOM A PAY SOURCE HAS BEEN EXPANSION OF NEIGHBORHOOD‐ BASED REDEVELOPMENT TO ALL HIGH POVERTY AREAS EXPANSION OF NEIGHBORHOOD‐ BASED CRIME PROGRAMS INTO ALL NEIGHBORHOODS INITIATIVES THAT KEEP YOUTH IN SCHOOL AND REDUCE THE DROP‐OUT RATE PARENTING CLASSESS MORE MEDICAL PRIMARY CARE PHYSICIANS EXPANSION OF CHILD ABUSE PREVENTION PROGRAMMING NEED FOR THERAPEUTIC IN‐ PATIENT TREATMENT NEED TO MAINTAIN & INTENSIFY DRUG ABUSE PREVENTION EFFORTS ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 17 I P a g e 4.3 PROGRAMS TO ADDRESS SUBSTANCE ABUSE Butte has long had a reputation as a “hard drinking” town, a reputation that is supported by crime and other data. In 2008, the County had a DUI crime rate 20% higher than the state rate. The rate of DUI crimes per 100,000 people increased by 135% between 2004 and 2008. Not only does this pose a threat to public health as intoxicated drivers take to the roads, but a cultural acceptance of substance abuse creates an environment in which children are at risk of neglect and abuse and one in which youth are more likely to engage in high risk behaviors. The 2008 Montana Prevention Needs Assessment Survey for Silver Bow County revealed that the rate of 8th, 10th and 12th grade students who engage in binge drinking is higher than both the state rate and an aggregated eight-state rate. The survey also revealed that a higher percentage of Butte-Silver Bow students believed their parents had attitudes favorable toward alcohol use and antisocial behaviors that is true statewide or in an eight-state area. There is grave concern about the extent to which youth in the county are abusing substances. It is out of this concern that community initiatives to curb underage drinking have emerged. Butte Cares, Inc., a non-profit organization, and the Mariah’s Challenge project aim to reduce and end substance abuse among Butte’s youth. The Butte-Silver Bow Health Department is engaged in initiatives to reduce risk factors and address substance abusing behaviors. The Department also focuses on prevention by providing drug and alcohol education to third and fifth grade students in the public elementary schools. There are a number of treatment, justice and housing services that address chemical addictions in the County. The Butte-Silver Bow Health Department provides outpatient counseling services, the Montana Chemical Dependency Center is located in Butte and provides inpatient addiction services. Butte-Silver Bow operates Drug and DUI Courts through their justice programs which are aimed at reducing recidivism. Homeward Bound is a transitional housing program where people who have completed treatment and have no housing options can stay for up to 2 years and receive support services. An analysis of services and needs reveals three gaps in services and programming related to substance abuse that require attention. First, there is currently no county-wide medical detoxification program. Breaking a substance addiction is a difficult physical process that often requires medical attention. Currently, people who attempt to break their addiction seek medical attention in the emergency room at St. James Healthcare which cannot provide the longer-term care required. A medical detox program has been identified over a number of years as a need for Butte-Silver Bow County. Secondly, continued grant funding to sustain the Drug and DUI Courts in the County is needed. Finally, that there is a substantial rate of substance abuse in the county points to a need to address the social norms that make this behavior acceptable. To this end, there is a need for more community education, particularly drug and alcohol education aimed at elementary school children. Educational programming that focuses on parents and the impact drug and alcohol abuse have on children in the home is also required. These gaps are illustrated in the chart below. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 18 I P a g e  Butte‐Silver Bow has a high rate of substance abuse and norms favorable to such abuse  The 2008 rate of DUI crimes in the County was 20% higher than the state rate  Percent of people who are reported to be heavy drinkers is higher than the median for statistical areas included in the  Substance abuse issues were highly emphasized as community problems by respondents to a 2004 environmental health survey  The 2008 Silver Bow County Prevention Needs Assessment indicates that Butte’s 8th, 10th and 12th grade students have a higher rate of binge drinking are at higher risk for antisocial behaviors and lack some important protective factors FINDINGS EXISTING SERVICES & INITIATIVES NEEDS  Outpatient chemical dependency services are provided by BSB Health Department; includes counseling for youth & adults; 125‐150 clients  Montana Chemical Dependency Center; In‐patient treatment‐  St. James Healthcare; ER‐emergency medical treatment  CCCS, Inc. provides in‐patient treatment for convicted felons  Drug & alcohol education is provided by the BSB Health Department to 3rd and 5th grade elementary school students in the public school system  The Butte‐Silver Bow Health Department is working on initiatives to address teen substance abuse and risk factors; they support Teens Advocating for Safe Communities and Safe Kids/Safe Communities programs promote drug and alcohol abstinence  Butte Cares; initiative to reduce substance abuse among youth  DUI Task Force; finding solutions to substance abuse in the county  Mariah’s Challenge; an initiative to end underage drinking through education and provision of scholarships to youth who take the challenge of not using alcohol/drugs Treatment services Prevention Programs & Initiatives Justice Programs Housing Programs for Recovery  Drug and DUI Courts; justice programs designed to reduce recidivism by providing treatment and monitoring for chemically dependent offenders  Homeward Bound; transitional housing for people without resources for housing including those leaving treatment  Hayes‐Morris House currently has 1 social detox bed for people with co‐occurring addition and mental illness; there are no medical detox programs in the county; people requiring medical attention for detox are currently seen in the ER at St. James Healthcare GAPS NEED FOR FUNDING TO SUSTAIN DUI AND DRUG COURTS Current Needs NEED FOR MEDICAL DETOX PROGRAM AND MORE SOCIAL DETOX BEDS NEED TO EXPAND DRUG & ALCOHOL EDUCATION IN SCHOOLS ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 19 I P a g e 5.0 KEY HEALTH FACTORS 5.1 SERVICES TO ADDRESS GENERAL HEALTH Underlying the beauty of Southwest Montana that conjures images of healthy living is a harsh reality. Butte-Silver Bow County is part of one of the nation’s largest superfund sites—the legacy of over 100 years of copper mining. In addition to the overwhelming task of addressing the apparent environmental degradation, the community struggles to overcome economic and social effects of the industry’s demise in the early 1980’s. Poverty is high; many families live in decaying neighborhoods and social ills like substance abuse and domestic violence are far too common. A significant portion of the working-age population moved away between 1980 and 2000, leaving a disproportionately high senior population. Coinciding with economic and age stressors in the environment are behavioral risk factors that lead to chronic illness. There is a high prevalence of tobacco use; 26% of the adult population currently uses tobacco which increases the risk of heart disease and heart attack. Exposure to second hand smoke can increase the risk of heart disease even for nonsmokers. Additionally, the 2008 Behavioral Risk Factor Surveillance System survey indicated a high percentage of adults who are overweight in the County. People with excess body fat are more likely to develop heart disease and stroke even with no other risk factors, and have lower life expectancy. Given these health risk behaviors, it is not surprising that Silver Bow County ranked high among statistical areas included in the 2008 in the percentage of adults with coronary heart disease. Heart Disease is the number one cause of death; the county’s rate per 100,000 people is significantly higher than both the state and national rates. The adult population fell well above the mean in two other indicative categories in the 2008 including the percentage of adults who had had a heart attack and the percentage of adults who had had a stroke. The high incidence of chronic illness and behaviors that contribute to its perpetuation point to the need for a health system that addresses both treatments and prevention; approaches that change obvious high risk behaviors are essential to improving population health. Chronic illnesses that are best managed through a primary care approach which focuses on coordination of services on behalf of patients should also become a focus. In order to strengthen this system, more primary care providers are needed. Butte-Silver Bow is currently designated by the U.S. Department of Health and Human Services as a Health Professional Shortage Area (HPSA) for primary medical care specifically for the low-income population. There is a need for the equivalent of 2.83 primary care providers to adequately serve the county population. It is also designated as a ‘Medically Underserved Area (MUA)’ by the Department. Thomson-Reuters is an international research firm with expertise in healthcare data, and its 2010 analysis of population-based physician needs indicates the Butte area (data provided by zip code) currently has a need for 15 full-time primary care physicians, which includes family practice, internal medicine, pediatrics, and OB-GYN physicians. Recruitment of more primary care providers will help ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 20 I P a g e strengthen the delivery system to the Butte area population. Recruitment of other specialty physicians also will continue. Even with successful recruitment efforts, the high incidence of chronic illness also calls for a system of communicating and coordinating services in a team environment to support a strong coordination of treatments and services. In addition to filling gaps in services to address chronic illness today and into the future, Butte-Silver Bow County, like other rural areas through the United States is faced with recruitment challenges. Shortages of physicians and other providers are common as many health care professionals seek work in more urbanized areas. Thus, there is a current need to address shortages in the areas of cardiology, endocrinology, urology, primary care, internal medicine and pediatrics. Continued focus on recruitment strategies and approaches will be necessary to fill these gaps. The following chart illustrates key health findings for Butte-Silver Bow, what is needed to address identified problems, existing services and identified gaps. Sources for the analysis included the 2010 Thomson-Reuters Area Physician Listing and Net Physician Need by Specialty, the 2010 American Medical Association Directory, the Blue Cross/Blue Shield Provider Network and the 2010/2011 Qwest Directory. St. James Healthcare Medical personnel were also a valuable source in developing the gaps analysis. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 21 I P a g e Current Needs  The leading cause of death in the County is heart disease; the death rate per 100,000 is higher than the state & national rates  43.4% of the adult population is overweight; county was number 2 /177 among statistical areas included in the 2008  26.1% of adults are current smokers  28% of pregnant mothers smoke during pregnancy—a full 10 percentage points higher than the state rate  16.2% of adults have been told they have asthma—higher than mean for areas included in the 2008  8% of adults have been told they have diabetes  Percent of adult men having a PSA test was below the mean among areas included in the  Percent of adults 50+ getting a colonoscopy or blood stool test was below the mean  30% of physicians are in internal medicine or family practice, below the national average  The County is short 2.83 primary care physicians for the population  Population is aging; more people in the 55 and older range  37% of population is at or below 200% of the federal poverty line Medical Services  There is currently 1 practicing Cardiologist; cardiology services are also provided once per week by 3 cardiologists who travel from elsewhere;  There are currently 23 practicing primary care physicians which includes family practice, internal medicine, pediatrics, and OB‐GYN physicians’ this is 15 short of Thomson‐Reuters population base recommendation for the area  St. James Healthcare provides full hospital Services; licensed for 100 beds  St. James Healthcare provides a certified Cardio Rehab Program for people recovering from a heart attack or stroke  There are currently 3 practicing general surgeons  There are currently no endocrinologists in the County  There is 1 licensed urologist practicing half‐time in the County  There are currently no gerontologists in the County  There are currently no physicians specializing in Allergies & Asthma  Health assessments are provided by nurses through the BSB Health Department for institutionalized people  Diabetes education is provided through the CHC, St. James Healthcare Foundation, the North American Indian Alliance and the YMCA  General Nutrition Education for people receiving food assistance through the Department of Health and Human Services SNAP program via Career Futures  Nutrition education and provision of nutritious food for pregnant and post partum mothers and their infants provided through the WIC program administered by the BSB Health Department; serves 700‐800 clients/month Nutrition Education  Family Planning Services (Title X) for reproductive health are provided by the BSB Health Department with fees based on income; serves 150 clients/week  CHC provides family planning services and related education in the public junior high and high school  Environmental assessments and clean‐up for mining‐related contaminants in homes is provided by the BSB Health Department in order to prevent illness associated with exposure to the contaminants  Immunization services once per week for children & youth at no or low cost and for adults at low cost are provided by the BSB Health Department  CHC provides immunizations daily to children, youth at no or low cost and adults at low cost  Cancer control and prevention services are provided by the BSB Health Department; provides financial assistance to low‐income people for screening; provides cancer education to area providers on current recommendations for standards of care  Maternal Child Health and Home Health Visits are provided by the BSB Health Department to improve positive pregnancy outcomes, decrease preterm deliveries and decrease related mortality rates  Education about the health effects of tobacco use is provided by the BSB Health Department  Case management services are provided through the BSB Health Department in order to provide an integrated approach to wellness that contributes to engaging more citizens in prevention measures  YMCA provides fitness facilities and programs for everyone in the community with some sliding fee opportunities; provides fitness programming to address childhood obesity Prevention and Wellness Programs and Initiatives FINDINGS GAPS NEEDS EXISTING SERVICES& INITIATIVES NEED TO CONTINUE RECRUITMENT EFFORTS FOR PRIMARY CARE AND OTHER AREAS AS THE MEDICAL WORKFORCE AGES NEED FOR MORE CARDIOLOGISTS NEED FOR ENDOCRINOLO‐ GISTS NEED FOR MORE UROLOGISTS NEED FOR MORE PRIMARY CARE PHYSICIANS NEED FOR MORE PUBLIC EDUCATION ABOUT PREVENTIVE HEALTH BENEFITS AND SERVICES NEED FOR MORE FOCUS ON PATIENT‐ CENTERED TEAM APPROACHES TO MANAGEMENT OF ILLNESS ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 22 I P a g e 5.2 SERVICES TO ADDRESS MENTAL HEALTH The number of people diagnosed in Butte-Silver Bow with a mental illness appears to be on the increase. The number of people served by the Western Montana Mental Health Center increased by 162% between 1997 and 2006. Perhaps the most alarming key findings that pertain to community mental health are a suicide rate that is higher than both the state and national rates and that the prevalence of Severe Emotional Disturbance among children 9 to 17 years of age which is significantly higher than the national rate. With so many children in this state of distress, the future will require the community to be vigilant about the provision of effective mental health services to intervene in this critical community health issue. A number of organizations exist in the community to provide well-designed and effectively delivered programs and services to address treatment, crisis support and basic necessities for people with such disabling illnesses that they have no or inadequate income. ACADIA, Inc., AWARE, Inc., the Butte Community Health Center and the Western Montana Mental Health Center provide in-patient, out-patient and therapy services. The Human Resources Council provides assistance with rent and medications for people who are awaiting approval for Social Security Disability income. A number of private clinicians provide therapy and counseling services in the county as well. The most glaring gap in services is seen in the area of There are currently no practicing in the County for adults and none that specialize in pediatric mental health. Many children who suffer from severe emotional problems are currently being sent to in-patient facilities outside the county and the state for treatment, which is not considered an optimal approach. Treatment provided in a child’s community allows for family and other social support that is considered critical to recovery. Thus, local in-patient treatment opportunities are lacking in the County. Also lacking are funds to assist families with payment of “wrap-around” services when Medicaid is not an option, insurance will not pay or only pays for limited and inadequate treatment time. An unfortunate loss to the community was the dissolution of the local Kids Management Authority which created a system of care for children with severe emotional problems and involved a high level of coordination among providers, funding sources and families. The following chart illustrates key findings related to mental health, needs, existing services and gaps in services and programming. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 23 I P a g e  The suicide rate at 27.5 per 100,000 population exceeds the state rate of 20.3; Montana consistently ranks in the top 5 states in the U.S. with regard to the suicide rate  The number of people served by the Western Montana Mental Health Center grew by 162% between 1997 and 2006  An estimated 11%‐ 13% of children aged 9‐17 were being treated for Severe Emotional Disturbance in 2006 and Therapy Services for Adults  AWARE, Inc. provides therapy and case management services to children and Youth  Community Health Center provides therapy to adults on a sliding fee basis  Western Montana Mental Health Center provides and therapy services as well as case management to people with mental illness including poor and low‐income people  There are no practicing in the county  There are 24 licensed clinical social workers, 17 clinical counselors and 3 in the county* FINDINGS NEEDS EXISTING SERVICES  ACADIA provides residential treatment to children and adolescents with co‐occurring behavioral, emotional and disorders  AWARE, Inc. provides therapy and case management services to children and Youth  Community Health Center provides therapy to children and youth on a sliding fee basis; child evaluation center evaluates and treats children who have been sexually or otherwise physically abused  Western Montana Mental Health Center provides therapy and case management services to children and youth  Butte School District #1 contracts with private mental health providers for therapeutic groups in school  There are currently no pediatric in the County and Therapy Services for Children & Youth  Western Montana Mental Health Center has a crisis response team that IS on‐call to provide evaluations in crisis situations  Western Montana Mental Health Center; the Hays‐Morris House provides 4 secure, involuntary beds in cases of court‐ ordered emergency treatment; 6 beds for crisis stabilization and 1 bed for social detox in a fully staffed facility in Butte  Western Montana Mental Health Center provides a transitional group home with 24 hour staffing Community‐ based crisis support and treatment for the severely mentally ill  Western Montana Mental Health Center; Silver House provides lunch Monday‐Friday and case management services to people with severe mental illness  HRC‐Butte‐Silver Bow Assistance Program; assistance with rent and medications while waiting approval for Social Security Disability Income  HRC; Homeward Bound provides transitional housing for adults, many of whom are mentally ill and without resources to obtain housing  There are 4 thrift stores that make available clothing for low‐ income people Assistance with meeting basic necessities GAPS THERE IS A NEED FOR MORE THERAPEUTIC IN‐PATIENT TREAMENT OPPORTUNITIES FOR CHILDREN WITH SED Current Needs THERE IS A NEED FOR MORE INCLUDING THOSE SPECIALIZING IN CHILDREN’S MENTAL HEALTH THERE IS A NEED FOR PROGRAMMING AND FUNDING FOR WRAP AROUND SERVICES FOR CHILDREN WITH SEVERE EMOTIONAL PROBLEMS A LOCAL SYSTEM OF CARE FOR CHILDREN WITH SERVERE EMOTIONAL PROBLEMS AND THEIR FAMILIES THERE IS A NEED FOR LICENSED MENTAL HEALTH PROFESSIONALS WHO ACCEPT MEDICARE AMD MEDICAID ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 24 I P a g e 5.3 SERVICES TO ADDRESS ORAL HEALTH A review of the population health status for Butte-Silver Bow County revealed key findings related to oral health. A significant number of adults have had all or some teeth extracted and the rate of these factors is well above the median for statistical areas included in the 2009 Behavioral Risk Factor Surveillance Survey A 2006 oral health plan and report prepared by the Montana Department of Health and Human Services indicates there are a number of factors in Montana that contribute to oral health deficiencies statewide. Large proportions of low-income people and seniors in the population are factors as is the large number of people who are uninsured. In Montana, which has one of the highest rates of uninsured in the nation, 60% of people are insured. Of those, only 20% have dental benefits. This creates an inability to pay and, therefore, a barrier to access which results in poor oral health. According the report, Montana also has a shortage of dentists to serve low-income populations, particularly those who depend on Medicaid (15% of Butte-Silver Bow’s population). While there are many dentists in the state who are enrolled in the Medicaid program, 41% of them saw only 20 Medicaid patients in the 2004- 2005 year reviewed for the oral health planning process. Although there is an equivalent of 19 full-time, licensed dentists practicing general dentistry in Butte-Silver Bow, the County is a designated Dental Health Professional Shortage Area (DHPSA) for the low-income population and is, according to the designation, short 2 full-time dentists to serve low-income people. The Butte Community Health Center is the only provider of general dental services on a slide fee basis; its dental clinic has 2 full-time dentists and 1 full-time hygienist. An important factor affecting the general dentistry into the future is an aging oral health work force; the average age of providers in Montana is 52 and the state is without a dental school to feed the work force. The following chart illustrates gaps in the oral health services within the context of key findings and existing services. ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T CHAPTER TWO: ANALYSIS OF GAPS IN HEALTH‐RELATED PROGRAMS/SERVICES 2‐ 25 I P a g e  The portion of the Butte‐Silver Bow population that has had all teeth or any teeth extracted was well above the median among statistical areas included in the 2009 Behavioral Risk Factor Surveillance System  Butte has a large low‐ income population; a significant number of people with health insurance have no dental benefits  There are a number of barriers to access for the senior population nationally; Medicare does not cover dental services; a large majority have no dental insurance; many seniors have trouble physically getting to a dental clinic FINDINGS NEEDS EXISTING SERVICES GAPS Current Needs THERE IS A NEED FOR 2 DENTISTS TO PROVIDE GENERAL DENTISTRY SERVICES TO THE LOW‐ INCOME POPULATION  There are currently 19 (FTE equivalent) licensed dentists practicing general dentistry in the county; ratio of population/providers is 1723:1, within the 3000:1 standard  The Community Health Center provides the only general dental services on a sliding fee; it currently has 2 FTE dentists  There are no pediatric dentists in the county General Dentistry  There are currently 2 licensed endodontic service providers in the county  There is currently 1 licensed oral/maxillofacial surgeon in the county Endodontic Services Oral ‐ Maxillofacial Surgery  There are currently 2 licensed, practicing orthodontists in the county Orthodontic Services Future Needs THERE IS A NEED FOR AT LEAST 1 PEDIATRIC DENTIST MORE DENTISTS WILL BE NEEDED TO REPLACE THE CURRENT AGING, DENTAL WORKFORCE AND TO SERVE A GROWING SENIOR POPULATON ---PAGE BREAK--- S I L V E R B O W C O U N T Y P U B L I C H E A L T H N E E D S A S S E S S M E N T NEXT STEPS 3‐1 I P a g e NEXT STEPS The Community Needs Assessment process was the first phase of a process to develop a Community Health Improvement Plan. Having completed the assessment, the next step will involve completion of a goal and strategy setting process which will lead to the final plan. To establish and prioritize a set of goals and strategies aimed at improving the health and environment for the county’s citizens, a set of focus groups meetings will be held during February and March to address needs in five identified public health areas including:  Needs of the Aging Population  Needs of the Low-Income Population  Environmental Health Factors (Physical Environment)  Social and Behavioral Factors  General Health Factors Once completed, resulting goals, strategies and priorities will be formally adopted by the County Board of Health and implemented by the Public Health Department along with its many community partners and collaborators. This process will be completed by June, 2011.