Full Text
Columbia Gorge Regional Community Health Assessment Collaborating for Optimum Health and Optimized Healthcare A summary of the needs and opportunities for improved health for the residents of the Columbia Gorge region including Hood River, Wasco, Sherman, Gilliam counties in Oregon and Skamania and Klickitat counties in Washington ---PAGE BREAK--- December 2013 P a g e I ii December 2013 The following people were instrumental in creating this document: Barb Seatter, M.S. Catherine Whalen, Coco Yackley, Ellen Larsen, RN, Erin Quinn, MSN, FNP, Julie Reynolds, PhD, Maija Yasui, Mark Thomas, Chaplain, Megan McAninch, MSc, Teri Thalhofer, RN, BSN ---PAGE BREAK--- December 2013 P a g e I iii The Cohort 1 About the Region 2 Demographics 2 Acknowledgment to the Consumer Community 4 Healthcare and Agency Ecosystem 4 Healthcare professionals 4 Acknowledgment to the Healthcare Professional Community 5 Social Service and Non-profit Agencies 6 Acknowledgment to the Agency and Faith Communities 6 How to Read the Results of the 7 BASIC NEEDS 8 Income insecurity 8 Housing insecurity 8 Food insecurity 9 Transportation insecurity 9 HEALTHCARE ACCESS 10 Health insurance 10 Have a Primary Care Provider (PCP) 11 Have a usual place for care 11 Distance from usual place of care 11 Physical health access 12 Dental health access 13 Mental health 14 Substance abuse treatment 15 Medications 16 HEALTH STATUS 17 General health and social isolation 17 Weight management 17 Physical health status 17 Mental health status 18 Physical and mental health together 19 Alcohol, tobacco and other drugs 19 Tobacco use 19 Problem drinking 19 Street drug use 20 Domestic/sexual violence 20 WE HAVE THE SAME NEEDS – a powerful 21 Limitations 21 METHODS and PROCESS 21 The MAPP process 21 Gathering Community Themes 21 Community Advisory Council 22 Behavioral Health Community Forum 22 Consumer Surveys by Mail 22 Consumer Surveys In-person 23 Focus groups 24 Gathering Health Status 25 Gathering Local Health Eco-system Status 25 Provider and agency input 25 MAPPing the Information Gathered 27 Gathering Forces of Change 27 Appendix 29 List of Figures and Tables 29 Community Health 30 MOU from the Cohort 37 Data from Truven Market Expert 2013. © Truven Health Analytics 42 Rank Order of Emergency Room Usage Frequency by 45 Community Needs Index (CNI) 46 ---PAGE BREAK--- December 2013 P a g e I 1 Columbia Gorge Regional Community Health Assessment Collaborating for Optimum Health and Optimized Healthcare A spirit of collaboration The organizations listed in the sidebar have come together to create our first integrated Columbia Gorge Regional Community Health Assessment. Together, we have been able to combine social and economic conditions with key healthcare information to build a prioritized set of needs for the region and identify unique needs in specific locations or populations. Historically, needs assessments were conducted separately for various populations and areas in the Columbia Gorge Region. Local organizations independently collected and analyzed data and implemented health improvement activities. As a result, efforts to prioritize needs and to collaborate on health improvement have been inconsistent and less impactful. This year, we pursued a different path using the newly formed Columbia Gorge Health Council with its Consumer Advisory Council as the organizer. With this new cross-organizational, cross-county forum, we chose to embark on a collaborative effort to serve the needs of multiple organizations. Our Principles of Collaboration outline our mutual intentions: A collaborative community health assessment (“CHA”) can be better; more accurate and actionable as community providers agree on the needs within our region and communities and will support our ability to address those needs together. A collaborative CHA will maximize collective resources available for improving population health. A collaborative CHA must be truly collaborative, requiring financial commitments from all participants who would use it to satisfy a regulatory requirement. While Community Health Assessments are often anchored in the healthcare ecosystem, we elected to be inclusive of the social service agencies and non-profits that serve the vulnerable populations in our area. This document represents our collaborative work and, more importantly, our harmonized voice on the highest needs for our region overall. The Cohort Columbia Gorge Health Council Hood River County Health Department Klickitat Valley Health Klickitat Valley Health Department Mid-Columbia Center for Living Mid-Columbia Medical Center North Central Public Health District One Community Health PacificSource Community Solutions Providence Hood River Memorial Hospital Skyline Hospital ---PAGE BREAK--- December 2013 P a g e I 2 About the Region The Columbia Gorge region lies on both sides of the Columbia River, in north central Oregon and south central Washington. It includes Hood River, Wasco, Sherman, and Gilliam counties in Oregon, and Skamania and Klickitat counties in Washington State. These six counties have a combined area of 8,560 square miles and a combined population of less than 84,000; only six cities in the region have a population greater than 1,000: The Dalles (13,620), Hood River^1 (7,167), Goldendale (3,407), White Salmon (2,224), Stevenson (1,465), and Cascade Locks (1,144). The region is primarily rural with some residents living more than an hour from healthcare. The four bridges that cross the Columbia River along the 60 miles of the region’s borders help connect the communities in the two states, as do interstate and state highways. There is no public transportation network that serves the region overall, but local public bus transportation options exist. Agriculture, tourism, forestry and healthcare services are the predominant industries with a very small but growing high tech industry contributing to the economic health of the Columbia Gorge region. Agriculture, tourism and forestry all have seasonal employment with the agricultural sector relying heavily on the presence of a migrant or seasonal farmworker population. The cost and availability of housing, especially in Hood River County, is influenced by seasonal recreational activity. The current total population of the area is expected to increase over the next five years from 84,482 to 87,932, an increase of 3,450 residents This increase will not happen equally across the counties, with changes ranging from an increase for Gilliam County to a decrease for Sherman County See Table 1 - Total Population below for a more detailed description of the population of the area. Table 1 - Total Population Source: Data from Truven Market Expert 2013. © Truven Health Analytics. Demographics The Columbia Gorge region has an increasingly older population, as do most rural counties. The Latino/Hispanic population in Hood River and Wasco counties is increasing rapidly. Native Americans and 1 Hood River County also has a city named Hood River. The notation Hood River^ will mean the city. All other references to Hood River are intended to be inclusive of the entire county. Figure 1 - Map of Columbia Gorge Region ---PAGE BREAK--- December 2013 P a g e I 3 Pacific Islanders are the other main racial groups resident in the region; African Americans are present in very small numbers (Table 2 on page Our region and Hood River in particular, has a high number of Latino/Hispanic residents. Within this population are a significant number of undocumented people, who face many additional challenges to meeting basic needs and to access healthcare. Themes related to legal status were strongly present in the Spanish focus group, specifically transportation barriers related to drivers’ licenses and ineligibility for health insurance. The size of the undocumented population is difficult to establish because disclosure of undocumented status could result in discrimination or deportation. Undocumented members of our community are therefore cautious about disclosing this status, even to each other, making the prevalence extremely difficult to measure. There are no formal studies or surveys regarded as accurate. Local agencies with trusted expertise in the Latino/Hispanic population estimate that conservatively, 30-45% of local Latino/Hispanic community members are undocumented and therefore categorically ineligible for many programs and benefits that support health. This ineligibility applies to the current expansion of Medicaid and government-subsidized health insurance plans under the Affordable Care Act. We anticipate that this population will continue to be largely uninsured. Based on these estimates and regional demographics, Hood River’s uninsured population could remain above 15% even after robust expansion of health insurance programs. Table 2 - Ethnicity and Race Source: Data from Truven Market Expert 2013. © Truven Health Analytics. ---PAGE BREAK--- December 2013 P a g e I 4 Acknowledgment to the Consumer Community For this first collaborative health assessment, it was vital to have a clear and undeniable voice of the consumers of health and healthcare services in the region. We used a 65-question survey that was delivered by postal mail and through specific in-person settings. The survey was available in English and Spanish. In addition, two focus groups were held – one for seniors and disabled; one for low-income Latinos/Hispanics. A large community forum was hosted for emphasis on mental and behavioral health needs. Across the community, we had over 1,000 detailed surveys completed, more than 100 attendees at the community forum and 31 individuals in the focus groups. We appreciate the time people took to participate and, more importantly, to share their perspectives and experiences. Gathering community feedback is both art and science. We would like to acknowledge the individuals and organizations who gathered this valuable input. The following agencies and individuals fielded hundreds of mail and in-person surveys and hosted, translated, transcribed and analyzed focus groups and recruited participants: The Center for Outcomes Research and Education (CORE); Marvin Pohl at Mid-Columbia Council of Governments and the Area Agency on Aging; Lorena Sprager, Joel Palayo and the Community Health Workers at the Next Door, Nuestra Communidad Sana; Megan McAninch from the Community Health Division, Interpreter Services and the Administrative Assistant pool at Providence; Mid-Columbia Medical Center; Mid Valley Elementary School; the Hood River Adult Center; Columbia Area Transit bus drivers; Meals on Wheels delivery staff; and Hood River, Klickitat and North Central Public Health departments. Healthcare and Agency Ecosystem Due to the relatively small size of the regional population, many healthcare professionals, social service agencies and non-profits in the Columbia Gorge Region serve patients and clients across county and state boundaries. This regional approach to a community health needs assessment provides a forum for multiple organizations to leverage our collective work for the benefit of the entire community. Healthcare professionals Four hospitals serve the Columbia Gorge region: Providence Hood River Memorial Hospital (Hood River^), Mid-Columbia Medical Center (The Dalles), Skyline Hospital (White Salmon) and Klickitat Valley Hospital (Goldendale). All but Mid-Columbia Medical Center are designated Critical Access Hospitals. Primary care is available in all six counties. Gilliam and Sherman county residents can receive care locally from mid-level providers. A mixture of mid-level providers and physicians serves the other four counties. In addition, the region has a Federally Qualified Health Center (FQHC), One Community Health, with offices in Hood River^ and The Dalles. There are several federally designated underserved areas and populations in the region (Table 3 on page 5) including those for migrant or seasonal farmworkers, Native Americans and income status. ---PAGE BREAK--- December 2013 P a g e I 5 Table 3 - Federal designations for under-served groups Hood River Wasco Klickitat Skamania Sherman Gilliam Medically Underserved Area (MUA) Medically Underserved Population (MUP) Migrant/ farmworker Migrant/ farmworker Native American Health Professional Shortage Area (HPSA) Migrant/ farmworker Migrant/ farmworker Migrant/ farmworker Low-income Low-income Mental Health Underserved Area Dental Health Underserved Area (DUA) Migrant/ farmworker Low-income Migrant/ farmworker Low-income Source: Health Resources and Services Administration (HRSA) County mental health services for Medicaid and uninsured residents with mental health, addictions or developmental disabilities are provided by three organizations determined by county: Mid-Columbia Center for Living serves residents of Hood River, Wasco, and Sherman counties, Community Counseling Solutions serves residents of Gilliam County and Central Washington Comprehensive Mental Health serves residents of Klickitat and Skamania counties. Mental health services in Hood River, Wasco and Klickitat Counties are provided by numerous professionals, including those in private practice and those employed by Providence Gorge Counseling and Mid-Columbia Outpatient Clinics. Four public health departments provide population-based services and maintain an overview of regional health status: Hood River Public Health Department serves Hood River County; North Central Public Health District covers Wasco, Sherman, and Gilliam counties; Skamania County Health Department and Klickitat County Health Department serve their respective counties in Washington. Dental care is available in all counties except Sherman and Gilliam, which are designated by the Health Resources and Services Administration (HRSA) as Dental Health Underserved Areas. Acknowledgment to the Healthcare Professional Community As a second set of inputs into this Community Health Assessment, we sought out the perspectives of the Healthcare Professionals in the region. We had over 140 professionals provide feedback and insights into the health and healthcare needs of the community using a relative rank approach. We would like to acknowledge the organizations that supported their employees in participating in this important activity: Table 4 - List of participating healthcare organizations Cascade Orthopedics Columbia Gorge Family Medicine Columbia River Women’s Center Deschutes Rim Clinic Hood River County Health Department Klickitat Valley Hospital Mid-Columbia Center for Living Mid-Columbia Medical Center Clinics and Hospital North Central Public Health District Northern Oregon Regional Corrections (NORCOR) Medical Group Northwest Pediatrics One Community Health OHSU Providence Hood River Medical Clinics & Hospital Skyline Hospital Summit Family Medicine ---PAGE BREAK--- December 2013 P a g e I 6 Social Service and Non-profit Agencies Social service and non-profit agencies assist the most vulnerable populations in the Columbia Gorge Region. Whether they are government or independent non-profit organizations, they help those who are disadvantaged by social or economic conditions. The relatively small size of the region’s population means agencies must work across long distances, and even state boundaries, to serve their clients. Agencies in the Columbia Gorge Region represent a broad cross-section of services that meet the basic needs and some healthcare needs of the population. Acknowledgment to the Agency and Faith Communities The agency and faith communities bring a critical eye to the social and economic conditions of our most vulnerable residents. We sought out their perspectives and insights into the health and healthcare needs of the community as a separate perspective from Healthcare professionals and consumers. We would like to acknowledge the organizations that supported their employees or volunteers in participating in this important activity: Table 5 - List of agency and faith community participants Area Agency on Aging Cascade Locks Bible Fellowship DHS Aging and People with Disabilities FISH Food Bank HAVEN Hood River Church of Nazarene Hood River Commission on Children and Families Hood River Fire and EMS Klickitat County Health Department Meals on Wheels – The Dalles Mid-Columbia Children’s Council Mid-Columbia Community Action Council Mid-Columbia Council of Gov’ts Mid-Columbia Fire and Rescue Mid-Columbia Medical Center – Community Outreach Providence Foundation Sherman County Court The Next Door, Nuestra Comunidad Sana Warming Shelter Wasco County Youth Services YOUTHTHINK ---PAGE BREAK--- December 2013 P a g e I 7 How to Read the Results of the Analysis The following pages include the results of the consumer surveys, consumer focus groups, agency experts, healthcare professionals and accredited data sources such as Truven and County Health Rankings. In the next several pages, you will see a table like the one below. 1. The topic heading and the key data points. The first row(s) in italics are responses to specific consumer survey questions (e.g. Any financial insecurity refers to responses to Questions 48-52 in the survey.). The full survey is included in the Appendix for reference. Focus Group Theme. If a Focus Group highlighted the topic as a barrier to accessing healthcare services, then 4 is shown. If the topic was not mentioned as a barrier to accessing healthcare services in the focus groups, then 0 is shown. The absence of an identified focus group theme should not be regarded as an absence of need in general. Focus groups were held in Hood River. Focus group sessions are planned for early 2014 in Wasco and Klickitat. Agency Rank and Healthcare Professional Rank are the relative ranking results from Agency and Healthcare Professionals. Relevant County, Truven or similar accredited data sources deemed highly important for context. It will be noted with a *2 or to indicate data source. Region-wide County Health Ranking data does not exist therefore those portions of the table will be grey. 2. Survey Source indicates ‘In-person’ for those surveys conducted at specific settings. ‘Mail’ indicates those results from the postal mail approach. N= represents the number of completed surveys and are called survey respondents throughout this document. 3. The Region column represents all six counties together. 4. By County View shows results for Hood River, Wasco and Klickitat counties. These counties have the highest amount of information across all categories and groups. Sherman, Gilliam and Skamania counties had smaller amounts of information making it unreliable to call out those counties separately. 5. Vulnerable populations were specific groups of interest including Migrant or Seasonal Farmworker (MSFW), Limited English Proficiency (LEP), Disabled, Households with incomes less than 200% Federal Poverty Level (<200% FPL) and respondents ages 65 and older For 2013, the 100% Federal poverty guideline is an annual income of $23,550 for a family of four; a single-person household is $11,490 or less. The 200% Federal poverty level is $44,100 for a family of four; $22,980 for a single-person. 2 Source: Data from Truven Market Expert 2013. © Truven Health Analytics. 3 Source: Data from County Health Rankings from http://www.countyhealthrankings.org/ ---PAGE BREAK--- December 2013 P a g e I 8 We designed our research to understand the needs of the vulnerable populations listed above. These groups did report higher needs in many areas. However, we also learned of significant needs identified by Native Americans in our region based on 37 survey responses either in-person or by mail. The degree of need in this population is worthy of further study and some of the narrative in this document will highlight the largest areas of need. BASIC NEEDS Income insecurity Mail survey. 23.5% of participants reported experiencing some kind of financial hardship over the past year. The most common form of hardship was food insecurity. The burden of healthcare bills was a challenge for 14.4% of participants. In-person survey. More than one in three (37.9%) participants reported experiencing some kind of financial hardship over the past year. As might be expected, financial hardship was more common among those with lower incomes. Latino/Hispanics and Native Americans were more likely to report financial hardship than non-Hispanic whites. Those under 54 were more likely to report financial hardship than those 55 and over. The burden of healthcare bills was a challenge for 20.5% of participants. Focus Groups. The Spanish-speaking focus group recognized income insecurity as a substantial barrier overall. Since the focus group format did not include specific questions on income, this feedback should be strongly regarded as a need. Table 6 - Income insecurity Housing insecurity Mail survey. Housing insecurity was not common among this population, likely because a mail survey would exclude those without published addresses. There were no statistically significant differences in rates of financial hardship by race/ethnicity. Women were significantly more likely to report experiencing financial hardship over the past 12 months than men were. In addition, financial difficulties appeared to lessen among individuals 55 and over. In-person survey. The In-person survey was not tied to a residential address; 7.0% of respondents reported housing insecurity. Focus Groups. Housing insecurity did not emerge as a theme from either focus group. The absence of housing as a theme means people did not specify housing as a primary barrier to accessing healthcare services. It should not be regarded as an absence of need for housing supports in general. Housing insecurity is based on responses to Question 50 – Did you or family members have to move in the last 12 months due to inability to pay rent, mortgage or utilities? While few in numbers, a response of Yes indicates a very disruptive circumstance to individuals and families. Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Income Insecurity N= 691 457 126 191 109 121 155 56 420 248 135 183 Any Financial Insecurity 38% 24% 17% 29% 29% 55% 52% 45% 48% 35% 20% 15% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 0 Agency Rank 2nd 2nd 1st Healthcare Professionals Rank 1st 1st 4th Unemployment** 6.0% 5.6% 7.0% 4% Region by County View Vulnerable Populations 2nd of 8 1st of 8 All 6 counties <200% FPL >65 4 0 ---PAGE BREAK--- December 2013 P a g e I 9 Table 7 - Housing insecurity Food insecurity Mail survey. Nearly one-third of those living below 100% of the federal poverty line reported experiencing food insecurity. 17.2% of mail respondents reported that they had been worried that food would run out before they had money to buy more. Those who identified as Hispanic or Latino were significantly more likely to experience food insecurity; 36% report that they experienced it in the past year. In addition, food insecurity lessens with age; those above 55 years of age reported much less food insecurity. In-person survey. The most common form of hardship was food insecurity: 31.8% of in-person respondents reported that they had been worried that food would run out before they had money to buy more. Latino/Hispanics and Native Americans are more likely to experience food insecurity than non- Hispanic whites. Nearly half of Latino/Hispanics (47.4%) and nearly two-thirds (65.2%) of Native Americans report experiencing food insecurity. Focus Groups. Food insecurity did not emerge as a theme from either focus group, but this should not negate the importance identified in the survey. The absence of food as a theme means people did not specify food as a primary barrier to accessing healthcare services. Table 8 - Food insecurity Transportation insecurity Mail survey. The vast majority of mail survey respondents (91.4%) report that they never have trouble accessing transportation. However, the 8.6% who do have trouble accessing transportation may be some of the most vulnerable in the community. Food insecurity was also high among those who report transportation barriers We also found significantly higher rates of current anxiety and depression among those who report transportation hardship. Those who were not experiencing transportation barriers were significantly less likely to list the emergency department as their usual source of care. Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Housing Insecurity N= 691 457 126 191 109 121 155 56 420 248 135 183 Could not afford; had to move 7% 1.6% 1.9% 2.0% 0% 4% 8% 5% 9% 3% 2% 2% Focus Group Theme 0% Q1 2014 Q1 2014 0 0 0 Agency Rank 1st 1st 1st Healthcare Professionals Rank 2nd 3rd 4th Owner Occupied* 55.0% 56.0% 60.0% High Housing Costs** 35.0% 33.0% 34.0% Region by County View Vulnerable Populations All 6 counties <200% FPL >65 0 0 0% 1st of 8 2nd of 8 Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Food Insecurity N= 691 457 126 191 109 121 155 56 420 248 135 183 Worried that food would run out 32% 17% 10% 20% 25% 53% 49% 36% 41% 27% 17% 10% Focus Group Theme 0% Q1 2014 Q1 2014 0 0 0 Agency Rank 4th 4th 3rd Healthcare Professionals Rank 3rd 2nd 2nd Limited Acces to Healthy Foods** 1.0% 15.0% 9.0% 0% Region by County View Vulnerable Populations All 6 counties <200% FPL >65 4th of 8 3rd of 8 0 0 ---PAGE BREAK--- December 2013 P a g e I 10 In-person survey. The vast majority of mail survey respondents (91.4%) reported that they never have trouble accessing transportation. Among In-person survey respondents, that number is only 80%. 62.5% of Native Americans report transportation barriers. 27.6% of migrant or seasonal farmworkers report transportation barriers, and 49.6% of the unemployed report transportation barriers. Since transportation can be an important factor in pursuing a job, this suggests that many people may be feeling “stuck” where they are. Focus Groups. All vulnerable populations recruited for the focus groups noted lack of transportation, though were also clear to note that it has improved over the past several years. A major concern amongst the MSFW and LEP group were access to driver's licenses or driver's cards. Since the focus group format did not include specific questions on transportation but rather barriers to accessing healthcare services, this feedback should be strongly regarded as a need. Table 9 - Transportation insecurity HEALTHCARE ACCESS Having health insurance, having a place you usually go for care and having a regular provider are generally associated with improved health outcomes. We wanted to know where residents in the Columbia Gorge area go for care, how far they have to travel to get there, whether they have a usual primary care provider and their insurance status. Health insurance status Mail survey. 89.8% of mail survey respondents report having some form of health insurance, including Medicare. Few respondents report receiving Medicaid benefits. The majority (87%) of respondents were insured for all of the past 12 months; 5% were insured for some but not all of the past 12 months. In-person survey. Compared to the mail survey rate, respondents in the In-person survey were much less likely to have health insurance. Employer-sponsored coverage is the most common form of insurance for this group. 13.6% of respondents receive Medicaid benefits. After those covered by private insurance, the next largest group (24.5%) is the uninsured. The majority (67.6%) of respondents were insured for all of the past 12 months; this is a much smaller proportion than the mail survey. 14.2% were insured for some but not all of the past 12 months. This response was our best indication of “churning” rates: the rate of those who move on and off insurance coverage. Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Transportation N= 691 457 126 191 109 121 155 56 420 248 135 183 Very difficult accessing when needed 20% 9% 5% 11% 14% 28% 27% 29% 24% 13% 16% 9% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 4 Agency Rank x of 8 3rd 3rd 2nd Healthcare Professionals Rank 5th 5th 5th 3rd of 8 5th of 8 All 6 counties <200% FPL >65 4 4 4% Region by County View Vulnerable Populations Figure 2 - Frequency of comments on healthcare access needs ---PAGE BREAK--- December 2013 P a g e I 11 Table 10 - Insurance status Have a Primary Care Provider (PCP) Mail survey. Respondents were asked to indicate whether they had one person that they usually thought of as their personal doctor or primary care provider (PCP). 83.3% of respondents said that they did have a PCP. There were no significant differences in access to a PCP by race or ethnicity. In-person survey. Respondents were asked to indicate whether they had one person that they usually thought of as their personal doctor or primary care provider (PCP). 73.4% of respondents said that they did have a PCP. Non-Hispanic whites, those who were 65 and older, and women were significantly more likely to have a PCP. Younger adults, Latino/Hispanics, migrant or seasonal farmworkers, and men were less likely to have a PCP. Have a usual place for care Mail survey. Having a place you usually go for care and having a regular provider are generally associated with improved health outcomes. 93% of all respondents indicated that they had a usual source of care. 70.2% of those with a usual source of care said that they usually go to a private doctor’s office or clinic. Those with incomes below 100% of Federal Poverty Level 100% FPL) were significantly less likely than others to list a private clinic as their usual source of care and significantly more likely than others to list a public health clinic or community clinic. Medicaid beneficiaries were significantly more likely than others to use a public health clinic, and so were Latino/Hispanics. In-person survey. 82.5% of all respondents indicated that they had a usual source of care. This is a lower rate than that among mail respondents. 93.7% of those with a usual source of care said that they usually go to a private doctor’s office or clinic. Demographically, the In-person survey respondents look more like the mail survey respondents who frequent public health or community health clinics — but only 2.8% of In-person survey respondents said that such a clinic was their usual source of care. Focus Groups. Four of the five vulnerable populations noted challenges with access to care, the outlier being those living with disabilities, which were underrepresented in the groups and usually already had an established relationship with the primary care provider. Distance from usual place of care Mail survey. More than half of respondents (54%) reported that they lived more than five miles of their usual place of care. For Latino/Hispanics, it was more common to live between 6 and 10 miles from their usual source of care. In-person survey. 60% of participants reported that they lived more than five miles from their usual place of care. For Latino/Hispanics, it was more common to live between 6 and 10 miles from their Hood River Wasco Klickitat MSFW LEP Disabled<200% FPL >65 Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Insurance Status N= 691 457 126 191 109 121 155 56 420 248 135 183 Without any health insurance 18% 8% 8% 15% 7% 51% 55% 11% 30% 16% 2% 4% Had insurance for only part of year 14% 5% 3% 6% 5% 22% 28% 7% 16% 4% 6% 2% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 0 4 4 Uninsured Adults** 29% 29% 23% Uninsured Children** 13% 13% 9% Region by County View Vulnerable Populations All 6 counties 4% ---PAGE BREAK--- December 2013 P a g e I 12 usual source of care. More than 50% of Native Americans reported that they live more than 20 miles from their usual source of care. Physical health access Mail survey. Notably, most adults who needed medical care got all the care they needed. Only 1% of respondents needed care but got none. When asked about reasons for unmet medical care needs, cost was the biggest factor. The uninsured were far more likely (86%) than the stably insured (50%) to cite cost as a factor. Medicaid beneficiaries were much less likely (21%) to worry about cost; they were also less likely to be concerned that their insurance wouldn’t cover needed care. For Medicaid beneficiaries, the most common reasons for going without needed care were not knowing where to go (33%) and not being able to get an appointment quickly enough There were no significant differences in common reasons by race/ethnicity. 23.4% of respondents have children living in their household, and 84.1% of those with children said that at least one of their children had needed medical care in the past year. Of those whose children needed care, 86.7% got all the medical care they needed. In-person survey. Most adults who needed medical care got all the care they needed. But the proportion of those who needed medical care and did not get it was much larger among the In-person survey population. When asked about reasons for unmet medical care needs, cost was the biggest factor. Even some of the respondents with insurance found that they couldn’t afford all the care they needed. 18.5% indicated that they thought they could handle their medical need without treatment. Nearly 40% of respondents have children living in their household, and approximately 77% of those with children said that at least one of their children had needed medical care in the past year. The overwhelming majority (89%) of children who needed care received all the medical care they needed. Focus Groups. Child physical health access emerged as a barrier from the Spanish-speaking focus group, again citing access to care, insurance coverage, and cost as the primary barriers. Note: Adult/Child N = number of adults and children respectively who needed Physical Healthcare within the last 12 months Table 11 - Physical health access Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Physical Health Adult/Child N= 491/200 361 / 89 130 / 39 131 / 42 73 / 16 74 / 48 90 / 71 49 / 6 309 / 161 199 / 64 106 / 90 141 Adult received no care when needed 5% 1.5% 1.4% 0.3% 2.5% 9% 8% 0% 6% 1% 0% 0% Child received no care when needed 0.5% 0.4% 0.0% 0.0% 3.4% 0% 1% 0% 0.6% 0% 11% 8% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 0 Agency Rank 1st of 4 1st of 4 1st of 4 Healthcare Professionals Rank 1st of 4 1st of 4 1st of 4 Region by County View Vulnerable Populations All 6 counties <200% FPL >65 4% 4 4 1st of 4 1st of 4 ---PAGE BREAK--- December 2013 P a g e I 13 Note: Respondents could select multiple reasons for going without care. Figure 3 - Reasons for going without Medical care Dental health access Mail survey. Dental care was the most common form of unmet need. One in five adults reported that they had unmet dental care needs within the past year. 80% of those with children said that at least one of their children had needed dental care in the past year. Of those whose children needed care, 78.6% got all the dental care they needed. More children went without needed dental care than without any other healthcare treatment. In-person survey. Dental care was the most common form of unmet need. More than one in five (27.5%) adults reported that they had unmet dental care needs within the past year. Three out of four respondents with children (74.4%) reported at least one of their children needed dental care in the past year; most children that needed dental care received all of the dental care they needed Focus Groups. All groups identified the need for better access to dental care, noting specifically the barriers of cost, appointment availability, and insurance coverage. Note: Adult/Child N = number of adults and children respectively who needed Dental Healthcare within the last 12 months Table 12 - Dental health access Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Dental Health Adult/Child N= 455/194 343/85 118 / 33 135 / 32 67 / 15 65/52 81/83 36/4 280/155 176/59 89/2 123/5 Adult received no care when needed 22% 13% 6% 13% 25% 22% 14% 27% 30% 19% 11% 14% Child received no care when needed 3% 6% 0% 14% 5% 0% 2% 0% 3% 9% 0% 9% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 4 Agency Rank 3rd 3rd 2nd Healthcare Professionals Rank 3rd 3rd 2nd ED Utilization Rank x of Top 20 7th 2nd 7th All 6 counties <200% FPL >65 4% 4 4 5th Region 3rd 3rd by County View Vulnerable Populations ---PAGE BREAK--- December 2013 P a g e I 14 Note: Respondents could select multiple reasons for going without care. Figure 4 - Reasons for going without Dental care Mental health access Mail survey. Behavioral healthcare was a less common need (13.4% of all mail respondents), but 50% of Adults who needed behavioral healthcare did not get all the care they needed. 17% of those with children said that at least one of their children had needed treatment or counseling for an emotional, developmental or behavioral problem. Of those, only 43.6% said that their child received all the care that he or she needed. Although the numbers of parents whose children require behavioral health treatment may be smaller, behavioral healthcare for children may be a significant unmet need in the Columbia Gorge area. In-person survey. Behavioral healthcare was a less common need, but 50% of Adults who needed behavioral healthcare did not get all the care they needed; primary reason being cost. Approximately 12.7% of those with children said that at least one of their children had needed treatment or counseling for an emotional, developmental or behavioral problem in the past 12 months. Of those, 54.5% said that their child received all the care that he or she needed. Focus Groups. The senior and disabled group strongly noted the need for better mental healthcare, particularly counseling or therapy services for depression. The key barrier that emerged was access and having too few mental health professionals in the area. Mental Health Community forum. Results of the Behavioral Health Community Needs assessment included improving access for hard-to-reach populations based on both geography as well as special needs such as veterans, migrant or seasonal workers and Native Americans. Suggestions also included to improve access by meeting with people where they are such as in schools, primary care offices, jails, churches, shelters and on the street. Participants also requested improved collaboration between multiple agencies that serve people with mental illness and addictions issues. Other identified needs included specialized training and services for children 0-7 years old, services for family members of people with addictions issues, and intensive recovery support for people with serious addictions and mental health issues, such as housing, employment and peer delivered support. Finally, recommendations included increasing availability, as wait times to see in the region were longer than other services. ---PAGE BREAK--- December 2013 P a g e I 15 Note: Adult/Child N = number of adults and children respectively who needed Mental Healthcare within the last 12 months. Due to the small numbers of adults and children seeking mental health services, the table includes only the Region view. Note: Respondents could select multiple reasons for going without care. Figure 5 - Reasons for going without Mental Health care Substance abuse treatment Mail survey. Substance abuse treatment and counseling was not a common need, but 50% of those who needed it did not get all the care they needed. In-person survey. Substance abuse treatment or counseling was not a common need (3.7% of all in- person respondents), but 50% of those who needed it did not get all the care they needed. Focus Groups. Substance abuse treatment was not recognized as an unmet need in either of the focus groups. Mental Health Community forum. Results of the Behavioral Health Community Needs assessment included improving access for hard-to-reach populations based on both geography as well as special needs, such as veterans, migrant or seasonal workers and Native Americans. Also suggestions to improve access by meeting with people where they are such as in schools, primary care offices, jails, churches, shelters and on the street. Participants also requested improved collaboration between multiple agencies that serve people with mental illness and addictions issues. Other identified needs included specialized training and services for children 0-7 years old, services for family members of people with addictions issues, and intensive recovery support for people with serious addictions and mental health issues, such as housing, Table 13 - Mental health access Survey Source In-person Mail Mental Health Adult/Child N= 123/33 61 / 18 Adult received no care when needed 24% 24% Child received no care when needed 12% 13% Focus Group Theme Agency Rank Healthcare Professionals Rank Region All 6 counties 4% 2nd 2nd ---PAGE BREAK--- December 2013 P a g e I 16 employment and peer delivered support. Finally, recommendations included increasing availability, as wait times to see in the region were longer than other services. Note: Adult N = number of adults who needed Substance abuse Treatment within the last 12 months. There was no separate question for Substance abuse treatment for children. Due to the small numbers of adults seeking substance abuse treatment, the chart includes only the Region view. Note: Respondents could select multiple reasons for going without care. Figure 6 - Reasons for going without substance abuse treatment Medications Mail survey. A large majority (81.6%) of respondents need some form of prescription medication. 83% of those need medications for physical health problems; 3.1% needed them for mental health or personal problems; and 13.8% need medications for both physical and mental health problems. In-person survey. A majority (70.3%) of respondents need some form of prescription medication. 79.3% of those need medications for physical health problems; 5.6% needed them for mental health or personal problems; and 15.1% need medications for both physical and mental health problems. Focus Groups. The Hispanic focus group identified access to medication as a challenge, particularly due to cost. It emerged at a slight level in the senior and disabled group, specifically related to transportation barriers. Note: Adult N = number of adults who needed Medications within the last 12 months. There was no separate question about Medications needed for children. Table 14 - Substance Abuse treatment access Survey Source In-person Mail Adult N= 25 6 Adult received no care when needed 22% 50% Focus Group Theme Agency Rank Healthcare Professionals Rank ED Utilization Rank x of Top 20 All 6 counties 0% Region Substance Abuse Treatment 2nd 2nd 20th ---PAGE BREAK--- December 2013 P a g e I 17 Table 15 - Medication access HEALTH STATUS General health and social isolation Mail survey. The majority of the Columbia Gorge mail survey respondents reported having good or excellent physical health Approximately one out of four respondents who were at or below 100% of the Federal Poverty Level (25.5%) or had only a high school diploma or less (26%) reported having fair or poor physical health. About one out of five unemployed respondents also reported fair or poor physical health. The proportion of mail survey respondents reporting fair or poor physical health was greater (16.4%) than those reporting fair or poor mental health Social isolation is an issue affecting more people: nearly one in five Columbia Gorge area residents may be socially isolated; 18.8% of respondents indicated that they would not have access to social support most of the time. In-person survey. The majority of respondents (78.7%) in the In-person survey also reported having good or excellent physical health; 21.3% reported having fair or poor health. However, the proportion reporting fair or poor physical health is greater for Latinos, community members who earn at or below 100% of the Federal Poverty Level, have only a high school diploma or less, and are unemployed. The proportion of In-person survey respondents reporting fair or poor mental health is less (13.8%) than those reporting fair or poor physical health However, rates of fair or poor mental health are above 25% for Native Americans, migrant or seasonal farmworkers, the unemployed, and those experiencing transportation hardships. Social isolation is more prevalent: nearly one in four (23.8%) respondents scored as socially isolated. Social isolation has been linked to poor mental and physical health outcomes. Weight management Mail survey. The most common risk factor in the Columbia Gorge area is the prevalence of overweight or obesity; over half of respondents reported that they were overweight. Native Americans were significantly more likely to report that they were overweight. In-person survey. The most common risk factor among respondents is being overweight or obese; over half of respondents reported that they were overweight. Physical health status Mail survey. Although most respondents rated their health as good, 61.3% of participants reported having been diagnosed with a chronic physical health condition (diabetes, asthma, high blood pressure, or high cholesterol). The most common chronic condition reported was high blood pressure. In-person survey. Chronic disease was still prevalent among In-person survey respondents, although less so than it was among mail survey respondents. 53.8% of participants reported having Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Medications Adult N= 473 376 123 147 78 55 60 53 287 227 126 162 Did not receive all meds needed 4% 1.0% 0.0% 1.3% 1.9% 6% 7% 8% 5% 2% 0% 0% Focus Group Theme 4% Q1 2014 Q1 2014 4 4 2 Region by County View Vulnerable Populations All 6 counties <200% FPL >65 4% 4 2% ---PAGE BREAK--- December 2013 P a g e I 18 been diagnosed with a chronic physical health condition. The most common chronic condition reported was high blood pressure. Table 16 - Physical health status Mental health status Mail survey. 29.2% reported that they had been diagnosed with a specific mental illness (depression, PTSD, or anxiety). 8.9% of respondents screened positive for depression, and 11.6% screened positive for anxiety. Rates of anxiety and depression were highest among the very poor (below 100% of the Federal Poverty Level), those with less education, and those who were experiencing unemployment. Those who had indicated that they were experiencing financial strain had high rates of anxiety current smokers and current street drug users also had high rates of anxiety. In-person survey. 21.4% report that they have been diagnosed with a mental illness. 10.1% of respondents screened positive for depression, and 11.8% screened positive for anxiety. Rates of anxiety and depression were highest among the very poor, the unemployed, and those who had experienced transportation hardship or social isolation. While there were no statistically significant differences by race for depression rates, Native Americans had higher rates of anxiety. Latinos had lower rates of depression and anxiety, which correlates with a lower incidence of mental illness diagnoses and better self-reported mental health among Latinos. Table 17 - Mental health status Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Physical Health Status N= 691 457 126 191 109 121 155 56 420 248 135 183 Consider themselves to be overweight 53% 56% 52% 55% 59% 42% 41% 59% 54% 57% 48% 55% Rate physical health Fair or Poor 21% 16% 12% 14% 29% 35% 34% 34% 29% 20% 15% 21% Report any chronic disease diagnosis 54% 61% 55% 63% 67% 35% 31% 39% 52% 60% 82% 77% Adult obesity** 23% 33% 27% Physical inactivity** 17% 20% 23% Region by County View Vulnerable Populations All 6 counties <200% FPL >65 Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Mental Health Status N= 691 457 126 191 109 121 155 56 420 248 135 183 Rate Mental Health Fair or Poor 14% 10% 6% 11% 12% 25% 23% 20% 17% 11% 9% 10% Screen positive for Depression 10% 9% 9% 9% 11% 9% 8% 20% 12% 10% 7% 11% Screen positive for Anxiety 12% 12% 10% 13% 11% 8% 6% 15% 12% 15% 4% 12% Report any mental health diagnosis 33% 29% 19% 45% 22% 22% 19% 41% 36% 32% 28% 30% Suicide rate per 100,000** 13.3 7.9 24.4 All 6 counties <200% FPL >65 Region by County View Vulnerable Populations ---PAGE BREAK--- December 2013 P a g e I 19 Physical and mental health together Mental health conditions have a strong connection with physical health conditions and mortality. 29.2% of mail survey respondents reported that they had been diagnosed with a specific mental illness. 61.3% of participants reported having been diagnosed with a chronic physical health condition (diabetes, asthma, high blood pressure, or high cholesterol). 20.6% overall reported having both a mental health and chronic physical health condition. Alcohol, tobacco and other drugs A topic ranked highly by Agencies and Healthcare professionals was Prevention of Risky Behaviors. Both expert groups felt strongly that Prevention and Health Promotion were similar in importance to Nutritious Food and Transportation. Tobacco use Mail survey. Smoking rates were lower among survey respondents than they are in the general population; 11.1% of respondents are current smokers, and 82.6% of those are currently trying to reduce or quit smoking. 3.9% report using chewing tobacco. Smoking was significantly more common among the very poor; the smoking rate for those at 100% Federal Poverty Level or lower is 20.6%. Latinos were significantly less likely to smoke; only 1.7% report currently smoking cigarettes. Smoking was also significantly higher among those ages 55-64. In-person survey. The smoking rate was higher (13.6%) than it was among mail survey respondents 3.4% report using chew tobacco. Problem drinking Mail survey. Problem drinking is less prevalent in the Columbia Gorge area than it is in the general population; 16.1% of respondents screened positive for a potential drinking problem (either binge drinking or heavy drinking). Problem drinking was more common with younger adults; respondents age 18-39 were significantly more likely to score as having a potential drinking problem. In-person survey. Problem drinking is much more prevalent among In-person survey respondents; 28% of respondents indicated a potential drinking problem (either binge drinking or heavy drinking). This high rate may be driven by the relative youth of the In-person survey population. Figure 7 – Overlap of chronic physical and mental health conditions ---PAGE BREAK--- December 2013 P a g e I 20 Street drug use Mail survey. 10.8% of respondents indicated that they were currently using a street drug; this result was driven largely by marijuana use. Drug use was significantly more common among the very poor. There is no statistically significant difference between Hispanic or Latino, whites or Native Americans in their use of all forms of street drugs. In-person survey. 9.8% of respondents indicated that they were currently using a street drug; this result was driven largely by marijuana use (only 2% reported using pain medications that were not prescribed to them, and 1.3% of the population reported using any street drug besides marijuana or pain pills). Table 18 - Alcohol, Tobacco and Drug usage Domestic/sexual violence Mail survey. Less than one percent of respondents reported ever experiencing sexual abuse or domestic violence. Domestic violence was very uncommon among all groups, and while Latinos and women were more likely to report sexual abuse, these results were also not statistically significant. In-person survey. Less than one percent of respondents reported ever experiencing sexual abuse or domestic violence. Prevalence of domestic violence and sexual abuse may be underreported. Social stigma leads to low rates of self-report in these domains. In addition, domestic violence was measured using the question, “Has anyone you lived with ever hurt or threatened to hurt you or your children,” and many respondents selected “I don’t know” instead of “no.” This response pattern suggests that domestic violence may be a more complex issue than can be captured with one question. Table 19 - Domestic violence Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail N= 691 457 126 191 109 121 155 56 420 248 135 183 Smoking Rate 14% 11% 6% 16% 11% 10% 5% 16% 15% 14% 6% 14% Smokeless tobacco 3% 4% 1% 4% 5% 1% 3% 0% 3% 3% 0% 4% Potential problem drinking AUDIT-C 28% 16% 21% 11% 12% 26% 27% 22% 27% 16% 14% 11% Marijuana or hashish use 9% 10% 13% 7% 14% 4% 2% 13% 11% 12% 2% 6% Street drug use 1.3% 0.6% 1% 1% 0.4% 0% 0.6% 2% 2% 0.6% 0% 0% Alcohol, Tobacco and Other Drugs Region by County View Vulnerable Populations All 6 counties <200% FPL >65 Hood River Wasco Klickitat MSFW LEP Disabled Survey Source In-person Mail Mail Mail Mail In-person In-person In-person In-person Mail In-person Mail Domestic Violence N= 691 457 126 191 109 121 155 56 420 248 135 183 Unsure of domestic violence 18% 23% 21% 23% 21% 10% 9% 27% 16% 24% 30% 29% Region by County View Vulnerable Populations All 6 counties <200% FPL >65 ---PAGE BREAK--- December 2013 P a g e I 21 WE HAVE THE SAME NEEDS – a powerful outcome With six counties, four hospitals, 2 states and a multitude of clinics, agencies, and public and mental health departments, we assumed were going to uncover significantly differing needs and differing priorities. Those concerns were unfounded. We learned that we share many of the same top concerns in Basic Needs and the same top concerns in Healthcare Access. Some communities may have the order different but the top concerns remain the same throughout the region. This outcome motivates us to continue collaborating on implementation plans as well as future assessments. Limitations We did a lot right in this first year. Nevertheless, there are always areas for improvement going forward. The three biggest gaps in the theme collection process are: 1) more focus on the Native American population 2) better inclusion of Dental health professionals and 3) better inclusion of schools and school- based clinics. None of these groups were excluded and we have some information from each, but a more explicit inclusion would yield a more comprehensive view. METHODS and PROCESS The MAPP process We decided to use Mobilizing for Action through Planning and Partnerships (MAPP) as the organizing model for our work. MAPP is an interactive, community-driven strategic planning process for improving community health by prioritizing health issues and identifying resources to address them. Its comprehensive perspective included input from local community members, social service agencies, and healthcare professionals. The MAPP assessment model seeks information in four key areas: 1) Community Themes and 2) Health Status, 3) Local Health Ecosystem, and 4) Forces of Change that make sure no important area is neglected. With this groundwork in place, we began to prepare the Community Health Assessment. We wanted to get input from the community (consumers, healthcare professionals, and agencies) to understand their perspectives on the health of the community. We gathered information from many sources: community forums, a Community Advisory Council, a behavioral health forum, agency worksheets and forums, provider surveys and forum, a consumer survey, an In- person survey, focus groups, and demographic data from several sources. Gathering Community Themes We used five different approaches to gather consumer inputs and community themes regarding Health and Healthcare concerns. Community Themes The health- related issues that are most important to community members Health Status The health of the community through quantitative data on key health indicators Local Health Eco-system The and challenges of our current local health and healthcare system Forces of Change The and challenges of our current local health and healthcare system ---PAGE BREAK--- December 2013 P a g e I 22 Community Advisory Council A Community Advisory Council (CAC) was formed in October 2012, to ensure the Community Health Assessment had input from broad segment of both consumers and providers of healthcare. CAC members were recruited from public venues and by word-of-mouth. More than 50% of the voting members needed to be active consumers or directly involved with individuals who are on Oregon Health Plan (OHP). Behavioral Health Community Forum A behavioral health community forum was held in Wasco and Hood River counties on May 13, 2013, and in Sherman County on May 21, 2013. Over 100 people participated in the Wasco/Hood River event; 25 people participated in the Sherman County event. The goals of both events were to find out what local mental health and addictions treatment programs should continue, start, or stop. We also wanted to review the and needs of the system to develop recommendations for improvements. Forum participants assessed our coordination of care, and reviewed access to services with regard to health equity. Feedback from the forum noted of the mental health system that included existing mental health promotion, mental illness prevention, and substance abuse prevention programs. Current treatment protocols had both and weaknesses. Problem gambling prevention and suicide prevention were seen as areas needing improvement. Service coordination with other agencies was another area needing improvement, as was behavioral health equity in service delivery, trauma-informed service delivery, stigma reduction, peer-delivered services, and crisis and respite services. Consumer Surveys by Mail We wanted to know consumers were able to access all aspects of care they needed physical health, counseling services, dental health, prescriptions, mental health). We wanted to understand the barriers to accessing care appointment times, hours, transportation, costs, daycare). We also wanted to learn about the depth and breadth of consumers’ current health and health habits. Finally, we wanted to know how the answers to these questions were related to population demographics (age, county of residence, ethnicity, etc.). The Center for Outcomes Research and Education (CORE) had been contracted to administer a consumer survey in the Providence service areas, including the Gorge. We were able to expand the reach and depth of the CORE survey through our regional collaboration. The Community Advisory Council, and the majority of participating agencies in this Community Health Assessment provided input to develop the survey. This approach accomplished three things: Reduce survey fatigue for consumers – one survey would collect data for multiple uses Provide trustworthy results for the Columbia Gorge region – CORE’s standardized questions have been tested for reliability and validity so results can be compared to others. Allow access to expertise and project management – CORE’s survey research unit could provide survey development, printing, mailing, follow-up, and analysis. The final consumer survey had 65 questions in multiple-choice format. CORE selected a simple random sample of 1,321 households in the Columbia Gorge region to receive a mail survey. We oversampled consumers in Wasco and Hood River counties, and low-income households in the region. A final tally of 457 mail surveys (an adjusted response rate of 35%) were collected from community members. (The Community Health Survey is in the Appendix on page 30.) ---PAGE BREAK--- December 2013 P a g e I 23 Compared to the known demographics of the region, the majority of mail survey respondents were ages 55 and older, and non-Hispanic white. More respondents were male (55.7%) than female Nearly two- thirds of respondents (63%) had household incomes at or below 200% of the Federal Poverty Level, and approximately 60% of respondents had completed a two-year degree or more. Although most respondents were employed, 41.8% were retired. Consumer Surveys In-person Some populations may be hard to reach with a mail survey, including groups for whom English is a second language, for instance, or those who are experiencing housing insecurity. In order to ensure that the voices of these hard-to-reach populations were considered, the Cohort listed on page 3 fielded surveys by hand. Volunteers and staff went to places where hard-to-reach populations might be found, and asked people in person to complete the survey. 1,000 surveys were printed for this purpose; 691 In-person surveys were completed yielding close to a 70% return rate The In-person survey filled many gaps left by the mail survey and is a useful complement. It included a higher percentage of women, younger people, and low-income individuals with less education. More of these respondents are employed and fewer are retired than in the mail survey sample. Our goal of reaching more Hispanics and those whose primary language is not English was highly successful. 26.2% identify as Hispanic or Latino, as compared to 1.5% of mail survey respondents. 23.1% say that English is not their primary language, as compared to 1.9% of mail survey respondents. 23.9% of In-person survey respondents were seasonal workers, and while we did not collect this information from mail survey respondents, seasonal workers may be less likely to be reached by a mail survey. The survey noted that the In-person survey responses may be especially useful because they demographically resemble the population eligible for Medicaid under the 2014 expansion. It includes a higher percentage of women. More of these respondents are employed and fewer are retired than in the mail survey sample. See Figure 8 for comparison details. Figure 8 - Comparison of Mail and In-person survey responses by demographic groups ---PAGE BREAK--- December 2013 P a g e I 24 The In-person survey reached a different population from the mail survey, and therefore their results should be treated separately. Since a convenience sample was used, differences in responses from different subpopulations should be considered significant only within this sample and are not necessarily generalizable. Focus groups Two focus groups were held to get a deeper understanding of the concerns of specific populations identified as vulnerable because of concerns related to the social and economic conditions that impact health: migrant or seasonal farm workers (MSFW), people with limited English proficiency (LEP), people living with disabilities, people with a low-income, defined as less than twice the Federal Poverty Level (<200% FPL), and seniors, defined as over 65 years We wanted to understand more about the barriers these populations might face in accessing healthcare and in having positive health outcomes within the healthcare system. The focus group participants were invited from the general public as members of two broad groups: Spanish-speaking and Seniors. In both groups, our recruitment approach aimed to include representatives of the above-named vulnerable populations. In practice, the Spanish focus group included very high numbers of migrant or seasonal farmworkers, people with limited English proficiency and people with low- income. One participant was disabled. The Seniors focus group was comprised predominantly of those over 65, but did include participants who were also low-income and/or disabled. Senior/disability. A focus group of 14 seniors (defined as “over the age of 65”) and disabled was held on October 24, 2013 in Hood River, for a discussion about unmet health needs and health resources within the community. The group ranged in age from 66 to 93 years old with 9 women and 5 men. There was one participant under the age of 60 who was wheel chair bound and arrived with a caregiver. The participants were all Caucasian, with the exception of one Japanese elder. In the Senior focus group, “health” was most often recognized as being an individual, independent pursuit of health-related activities and behaviors. Seniors mentioned “role-reversal,” and becoming dependent upon one’s children for transportation and care. Some of the major unmet health needs discussed were loss of independence, the depression that often accompanies it, dental care, respite for caregivers, and a lack of transportation or activity options. Hispanic/low-income. The Hispanic focus group of 17 persons was conducted in Spanish during October in Odell, Oregon. We invited low-income Spanish-speaking families to join us for a discussion about unmet health needs and health resources within the community. “Health” was recognized as being very much a family-focused value, which lies in the community more so than the individual. Health was also strongly associated with “being happy.” The greatest expressed need was that of insurance, access to affordable healthcare, and dental care. Transportation, specifically driver’s licenses, also emerged as a significant barrier—all participants recognized that it was a barrier for either themselves or someone they knew. Many noted that they only access care in an emergency, largely due to concerns regarding cost. Additionally, as many participants identified as Farm Workers, the use of pesticides and subsequent prevalence of asthma in children was a concern. Many participants expressed concern that the doctors at health resources within the community, particularly low-cost clinics and those with payment plans, were less qualified than the doctors at the hospital. Other solutions included the use of community health workers to provide education about nutrition and hygiene and to support those living with chronic conditions. ---PAGE BREAK--- December 2013 P a g e I 25 Gathering Health Status We used Health Status information from three primary sources: 1. Providence Health and Services facilitated access to Truven Health Analytics demographic data, general population data as well as Community Need Index4 information 2. County health departments furnished County Health Rankings demographic and Health Status information 3. Self-reported health and chronic conditions through the Consumer Survey – both mail and In- person Gathering Local Health Eco-system Status Provider and agency input As a community, we were concerned not only with people’s unmet healthcare needs, but also their unmet basic needs (like food and housing), which take into account the importance of the social and economic conditions that impact health. Many health and healthcare organizations had conducted independent health assessments in previous years. Using the numerous previous assessments combined with insights from the Community Advisory Council, two grids were constructed that intersected unmet needs with their attributes. Although agencies generally deliver the services on the Basic needs grid and Healthcare professionals deliver the services on the Healthcare needs grid, both groups were asked to prioritize the Top 5 on each grid, giving a complementary view into each other’s discipline as well as their own. The combination of a category Food) with an attribute Cost) forced the participants to be specific about their top concern, but allow us to look at attributes taken together (e.g. ‘Cost is the highest concern across all categories’). The list of participating agencies is in Table 5 - List of agency and faith community participants on page 6. Basic Needs Grid Safe Convenient Available Language Cost Nutritious Food Stable Housing Transportation Living Wage Education Family Support Services Exercise/Sports Prevention of risky Health Behaviors (tobacco, unsafe sex, alcohol, drugs) 4 Data and methodology for the Community Need Index (CNI) for use in this publication were supplied by Truven Health Analytics. Dignity Health contributed to the development of the methodology as well. Any analysis, interpretation, or conclusion based on these data is solely that of the authors, and Dignity Health and Truven Health Analytics disclaim responsibility for any such analysis, interpretation or conclusion. ---PAGE BREAK--- December 2013 P a g e I 26 Healthcare Needs Physical Health Behavioral Health Dental Health Emergency Services Location Hours Appointment Access Urgent Care Access Language Cost to Client Services Not Covered These two grids, Basic Needs and Healthcare Needs, provided the framework for the Agency Sessions and Provider Survey. Agency rankings and sessions. Agency representatives ranked what they believed to be their clientele’s top 5 unmet basic needs, and the top 5 unmet healthcare needs, using the grids above, and provided written comments about access to healthcare and the barriers to care. Nineteen agencies provided input and the responses were collated for use in two agency sessions, held June 16 in The Dalles, and June 18 in Hood River. Twenty-two organization representatives participated in the two sessions. The moderator for the sessions presented the collated rankings and facilitated a process to collectively refine the rankings and gather further insights about these needs. Participants were asked to place five sticky notes numbered 1-5 on a poster showing the areas of greatest unmet basic needs, and another five numbered sticky notes on a different poster to indicate the areas of greatest unmet healthcare needs of their clients. Two additional organizations provided their information after the facilitated sessions. Healthcare Professionals session and survey. An online survey to gather the same information was distributed to healthcare professionals across all six counties in July, asking them to rank unmet basic and healthcare needs, in the same format as the agency sessions. 114 surveys were completed by Healthcare Professionals representing many disciplines, including physicians, dentists, nurses, physician assistants, physical therapists, dieticians, pharmacologists, specialty MDs, pharmacists, primary care, OB-GYN, and nurse practitioners. In October, five physicians responded to an invitation to review the rankings submitted by agency and healthcare professionals, and discuss the top-ranked basic and healthcare needs of patients in the region. The conversation was facilitated and their input was documented. The overall agreement among social service agencies and Healthcare professionals on the “Top 5” unmet needs on the Basic Needs and Healthcare Needs was a surprise – we assumed that healthcare professionals and agencies would have very different perceptions of unmet needs, but their priorities were quite similar. There were small differences in the rankings, but: Adequate income and stable housing were #1 or #2 Food and transportation were #3 or #4 Prevention ranked #5 Availability and cost were the two predominant attributes Healthcare professionals, but not agencies, were asked where the majority of their patients lived. Those who said that most of their patients were from Hood River prioritized stable housing higher, while those who said most of their patients were from Wasco County prioritized nutritious food higher. The list of participating healthcare organizations appears in Table 4 - List of participating healthcare organizations on page 5. ---PAGE BREAK--- December 2013 P a g e I 27 MAPPing the Information Gathered Across the various methods and process, the collective information gathered for this health assessment was quite extensive. The diagram to the right summarizes the data gathered across the main categories’ of the MAPP model. Gathering Forces of Change Throughout the process, there have been a few opportunities to collect a list of Forces of Change. The current list includes: Healthcare Eco-system changes o New certified medical interpreter standards o Potential for regionalized public health via legislation o ICD-10 and DSM-5; affects what’s diagnosable and what’s covered o Aging PCP workforce and aging population Bottleneck at federal level for funding primary care education and residency programs—this results in shortages Use of physician extenders is helping mitigate the shortages Is there a way to use physician skills in flexible ways that meets needs of an aging workforce (e.g. , less intense time or skill commitment, overseeing hospice programs, etc.) Increasing attention to palliative care needs; there’s a huge opportunity to help families navigate late-life healthcare issues We’re trying to orient more toward community-based and in-home services versus hospital and office-based care May be a need to change practices so that docs go to homes No way to pay for home visits right now Maybe we need team-based care with an NP and a doc, other staff, who see a group of patients How do we make new practice models financially viable and rewarding to docs (in terms of pace, etc.)? Insurance coverage changes o Does Hood River County decision to move to PacificSource have impact or potential opportunity? o Inclusion of OEBB/PEBB (Public Employees Benefit Board) into CCO o Insurance changes affecting contractual agreements between payers and providers and shifting provider networks o Inclusion of dental into CCO Community Themes Consumer Survey – >1,000 surveys Community Sessions – >100 participants 2 Focus Groups - Hispanic + Seniors/Disabled Health Status Truven ® Demographic Data County Health Rankings Self-reported status from Consumer Survey Local Healthcare Eco-system Agency Sessions – 24 agencies; 5 counties Provider Sessions – 114 healthcare professionals; 4 hospitals; 4 Health Depart’s Forces of Change Gathered in Agency Sessions, Provider Session, CAC meeting ---PAGE BREAK--- December 2013 P a g e I 28 o Affordable Care Act implementation in January 2014: unknown impact on medical, behavioral, and dental health healthcare; great concern for the capacity of the current system and practitioners available. o Medicaid expansion o Will the sum of all the healthcare changes result in significant contract shifts such as Providence and HealthNet. o Insurance Exchange—will trend of shifting costs to employees change. What will happen to those who end up not purchasing and paying higher taxes? Will it be cheaper and better coverage purchasing on your own? o Global budget could affect services General Health and Population changes o Aging population; nuclear families not as common—will we have enough residential care; assisted living; skilled nursing facilities? o Increasing birth rate o Legalization of marijuana Immigration reform o Driver licenses for undocumented—unless new legislation goes into effect o Immigration law and access to Medicaid or other benefits o Immigration reform – depending on how it evolves, many of our current residents could qualify for services. ‘Built’ Environment changes o Early Learning Hubs o Only 1% of EMS responses are for fires; 99% are other emergency response services o Coal trains through the Gorge o Land use planning o Federal ownership of land; loss of timber payments – how will elimination of these revenues affect county services? Environmental Factors o Need winter walking facilities or low-impact exercise facilities for patients o 25 people showing up every Monday for Zumba class, especially Latinos ---PAGE BREAK--- December 2013 P a g e I 29 Appendix List of Figures and Tables Figure 1 - Map of Columbia Gorge Region 2 Table 1 - Total 2 Table 2 - Ethnicity and 3 Table 3 - Federal designations for under-served 5 Table 4 - List of participating healthcare organizations 5 Table 5 - List of agency and faith community participants 6 Table 6 - Income insecurity 8 Table 7 - Housing insecurity 9 Table 8 - Food insecurity 9 Table 9 - Transportation insecurity 10 Figure 2 - Frequency of comments on healthcare access needs 10 Table 10 - Insurance status 11 Table 11 - Physical health access 12 Figure 3 - Reasons for going without Medical care 13 Table 12 - Dental health access 13 Figure 4 - Reasons for going without Dental care 14 Table 13 - Mental health access 15 Figure 5 - Reasons for going without Mental Health care 15 Table 14 - Substance Abuse treatment access 16 Figure 6 - Reasons for going without substance abuse treatment 16 Table 15 - Medication access 17 Table 16 - Physical health status 18 Table 17 - Mental health status 18 Figure 7 – Overlap of chronic physical and mental health conditions 19 Table 18 - Alcohol, Tobacco and Drug usage 20 Table 19 - Domestic violence 20 Figure 8 - Comparison of Mail and In-person survey responses by demographic groups 23 ---PAGE BREAK--- December 2013 P a g e I 30 Community Health Survey ---PAGE BREAK--- December 2013 P a g e I 31 ---PAGE BREAK--- December 2013 P a g e I 32 ---PAGE BREAK--- December 2013 P a g e I 33 ---PAGE BREAK--- December 2013 P a g e I 34 ---PAGE BREAK--- December 2013 P a g e I 35 ---PAGE BREAK--- December 2013 P a g e I 36 ---PAGE BREAK--- December 2013 P a g e I 37 MOU from the Cohort ---PAGE BREAK--- December 2013 P a g e I 38 ---PAGE BREAK--- December 2013 P a g e I 39 ---PAGE BREAK--- December 2013 P a g e I 40 ---PAGE BREAK--- December 2013 P a g e I 41 ---PAGE BREAK--- December 2013 P a g e I 42 Data from Truven Market Expert 2013. © Truven Health Analytics ---PAGE BREAK--- December 2013 P a g e I 43 ---PAGE BREAK--- December 2013 P a g e I 44 ---PAGE BREAK--- December 2013 P a g e I 45 Rank Order of Emergency Room Usage Frequency by Diagnosis Below is the rank order listing of the most frequent diagnoses for Medicaid (OHP), uninsured and dual eligible (Medicaid and Medicare) patients for 2013. If the same number appears twice in a row, it means the total count was the same for those rows. For example, under Skyline Rank Order, there are two rows that are 7th – Chest Pain and Fever, unspecified. Both rows had an equal amount of patient encounters in the emergency room for those two diagnoses. Row Labels Regional Rank Order Rank Order MCMC Rank Order KVH Rank Order Skyline Rank Order Upper Respiratory Infection 1 1 1 1 1 Abdominal Pain (all locations & unspecified) 2 2 4 2 2 Vomiting and/or Nausea 3 11 7 5 3 Chest Pain 4 13 3 3 7 Tooth/Supporting Structure 5 7 2 7 Fever, unspecified 6 9 10 4 7 Lower Back Pain and/or Sprain 7 4 5 10 Headache 8 8 9 6 8 Rashes 9 12 9 4 Urinary Tract Infection 10 5 12 6 Wound, Fingers or hand 11 10 11 15 Head and/or face injury/wound (except eyes) 12 12 11 8 Viral Infection 13 3 Shortness of breath 14 10 8 Patient left without being seen 15 6 Sprain of ankle 16 14 14 Pregnancy related 17 6 Change Surgical dressing 18 8 Dehydration 19 5 Alcohol Abuse 20 11 Diarrhea 21 10 Administrative Encounter 22 13 Pain in limb 23 13 ---PAGE BREAK--- December 2013 P a g e I 46 Community Needs Index (CNI) In 2005 Dignity Health, in partnership with Truven Health, pioneered the nation’s first standardized Community Need Index (CNI). The CNI identifies the severity of health disparity for every zip code in the United States and demonstrates the link between community need, access to care, and preventable hospitalizations. To determine the severity of barriers to healthcare access in a given community, the CNI gathers data about that community’s socio-economy. For example, what percentage of the population is elderly and living in poverty; what percentage of the population is uninsured; what percentage of the population is unemployed, etc. This data is used to assign a score to each barrier condition (with 1 representing less community need and 5 representing more community need). The scores are then aggregated and averaged for a final CNI score (each barrier receives equal weight in the average). A score of 1.0 indicates a zip code with the lowest socio-economic barriers, while a score of 5.0 represents a zip code with the most socio- economic barriers. Data and methodology for the Community Need Index (CNI) for use in this publication were supplied by Truven Health Analytics. Dignity Health contributed to the development of the methodology as well. Any analysis, interpretation, or conclusion based on these data is solely that of the authors, and Dignity Health and Truven Health Analytics disclaim responsibility for any such analysis, interpretation or conclusion.