2015 Community Health Needs Assessment
Sinai Hospital of Baltimore
Northwest Hospital
Levindale Hebrew Geriatric Center and Hospital
Carroll Hospital*
LifeBridge Health… Caring for Our Communities, Together!
TABLE OF CONTENTS
I. Executive Summary …………………….……………………………….……………………………..3
II. LifeBridge Health Overview ………………….….…………………………………………….…..4
A. The CHNA Process ………………………………………...…………………..……….………...………6
III. Sinai Hospital of Baltimore ……………..………..…………………....…….............…….10
A. Community Demographics & Public Health Data ..……...……………………………….10
B. Survey Results & Implementation ....……………………..………………………….………….16
C. Prioritized Needs ..……………………………………………………………………………….……….19
D. Needs Not Addressed Within Implementation Strategy….…………………….……...20
IV. Northwest Hospital …………………………………………………….. …….....……….……….23
A. Community Demographics & Public Health Data ...……………….…………….……….23
B. Survey Results & Implementation ……..…………………………….…………………….…….27
C. Prioritized Needs ..…………………………………………………………………………….………….30
D. Needs Not Addressed Within Implementation Strategy …...……………….………...31
V. Levindale Hebrew Geriatric Center and Hospital …..…………………………....…….33
A. Community Demographics & Public Health Data ...……………………………..……….33
B. Survey Results & Implementation ...……………………………………………………..…..….36
C. Prioritized Needs ..………………………………………………………………………………..……...39
D. Needs Not Addressed Within Implementation Strategy ..…………………….….…...40
VI. LBH Resources and Partners ..……………………...……………………….…….……..…….42
VII. Appendix ………………………..……………………...……………………….……………….…….44
A. Appendix A. 2015 CHNA Survey…………...…………....……………………………….….…...44
B. Appendix B. Kujichagulia Progress Report .…………………………………………......…..46
C. Appendix C. Changing Hearts Progress Report …………………………………….….…...49
D. Appendix D. Stop Abuse of Elders (SAFE) Project Progress Report ..…….…….….52
VII. References.. ……………………..……………………....……………………….………..….…….53
EXECUTIVE SUMMARY
LifeBridge Health (LBH) conducted its Community Health
Needs Assessment (CHNA) in fiscal year 2016 (July 1, 2015
– June 30, 2016). The CHNA complies with the Internal
Revenue Service (IRS) mandated requirement for all notfor-profit 501(c)(3) hospitals every three years.
Involvement of residents, stakeholders, and community
partners was an essential component of the LBH CHNA
process.
The process used to identify health needs of communities
in the LBH service areas included analyzing primary and
secondary health data at both the hospital and community
level, and involving public health experts, community
members and key community groups in further
identification of priority concerns and needs. The CHNA
team collected and analyzed a total of 1,530 surveys (Sinai,
921; Northwest 564; Levindale, 45) from individuals living
in LBH Primary Service Area zip codes. The CHNA team
then presented the initial findings at six community
forums, attended by community residents and
stakeholders to gather direct feedback for preliminary
identified needs.
The CHNA team evaluated this feedback and data
collected to prioritize recommendations for Sinai,
Northwest and Levindale, respectively, to address top
community health concerns. An assessment of hospital
resources, expertise and capacity led to a decision to
expand and enhance the community health improvement
projects that resulted from the 2012 CHNA process.
These projects focused on the heart disease cluster for
each institution, with additional programming focusing on
Street Violence for Sinai, domestic violence in the elderly
population for Levindale and the expansion of community
education services across the health system.
The Board of LifeBridge Health, Inc., approved the plans
for continuation of Community Health Improvement
Projects at each institution on April 21, 2016. The boards
of Sinai, Northwest and Levindale as well as the LifeBridge
Health Community Mission Committee approved the plans
for continuation as follows:
Hospital/ Committee
Name
Date of Board
approval
LBH Community Mission
Committee
March 8, 2016
Sinai Hospital
April 28, 2016
Northwest Hospital
April 25, 2016
Levindale Hebrew Geriatric
Center and Hospital
June 6, 2016
*Although Carroll Hospital became an entity of LifeBridge Health in April of 2015, the institution completed its CHNA on a separate schedule.
LIFEBRIDGE HEALTH OVERVIEW
Overview of Sinai Hospital of Baltimore
Founded in 1866 as the Hebrew Hospital and Asylum, Sinai
Hospital has evolved into a Jewish-sponsored health care
organization providing care for all people. Today, Sinai
Hospital is a 504-bed community teaching hospital that
provides patient care in a variety of settings including
inpatient, surgical, outpatient, trauma center (Level II
designation), high risk Neonatal Unit, state-of-the-art
Emergency Department, and responsive community
outreach provided by M. Peter Moser Community
Initiatives department (Community Initiatives), an integral
part of the Population Health Department. Sinai Hospital
has 11 specialized clinical Centers of Excellence, including
the Alvin & Lois Lapidus Cancer Institute, Sandra and
Malcolm Berman Brain & Spine Institute, and the Herman
& Walter Samuelson Children’s Hospital.
Sinai Hospital is the most comprehensive and largest
community hospital in Maryland, and is the state’s third
largest teaching hospital. Community teaching hospitals
such as Sinai find one of their greatest strengths is their
clinicians’ commitment to direct patient care. The
residents and medical students who train at Sinai have
chosen a community-teaching setting over a classic
academic medical center setting. Sinai provides medical
education and training to 2,000 medical students,
residents, fellows, nursing students, and other health
professionals each year from the Johns Hopkins University,
Overview of Northwest Hospital
University of Maryland, and other teaching institutions in
Northwest Hospital Center (NWH) is an acute care, 268the Baltimore/ Washington/ Southern Pennsylvania
bed community hospital located in Randallstown,
region.
Maryland. It has 245 licensed acute care beds, 39 subacute beds, and a 14-bed inpatient hospice unit. The
Sinai Hospital is a member of the LifeBridge Health system,
hospital was originally established in 1962 as the Liberty
which was formed in 1998 by the merger between Sinai
Court Rehabilitation Center. A year later, the Center
Health System, Inc., that included Sinai and Levindale
changed its name to the Baltimore County General
Hebrew Geriatric Center and Hospital, and Northwest
Hospital, and in 1993, made a final change to the
Health System, Inc. A fourth hospital, Carroll County
Northwest Hospital Center. LifeBridge Health System, the
Health Services Corporation, joined the LifeBridge Health
parent corporation, was formed by the merger of Sinai
system in April 2015.
Health System, Inc. and Northwest Health System, Inc. in
October 1998.
Sinai Hospital completed its formal community health
needs assessment as required and defined by the Patient
Today, Northwest Hospital maintains its mission to
Protection and Affordable Care Act and Section 501(r)(3)
improve the well-being of the community by nurturing
of the Internal Revenue Code during fiscal year 2016
relationships between the hospital, medical staff and
(FY16).
patients, while providing the highest quality of care in a
patient-centered environment. NWH delivers a broad
array of inpatient, emergency and outpatient services to
LIFEBRIDGE HEALTH OVERVIEW
residents throughout the northwest corridor of the state,
including Baltimore County, southern and eastern Carroll
County, Baltimore City, and northern Howard County.
In 1927, the residents of the Hebrew Friendly Inn and Aged
Home moved to a 22-acre lot at Greenspring and
Belvedere Avenues in Baltimore, the former home of the
Jewish Children’s Society orphanage. The facility was
As a community focused hospital center, NWH’s services
renamed Levindale, in honor of Louis Levin, secretary of
respond to a broad continuum of health care needs and
the Children’s Society and first Executive Director of the
serves patients either directly, through joint programs with Associated Jewish Charities.
other providers and health related agencies, or as an
advocate for alternate sources of care. Northwest Hospital Today, Levindale has evolved into a 330- licensed-bed
operates 10 Centers of Excellence including the Sandra
facility. Levindale's geriatric center includes 126
and Malcolm Berman Brain & Spine Institute, the Herman comprehensive care (long-term care) beds, 35 sub-acute
& Walter Samuelson Breast Care Center and the Krieger
beds, 28 dementia care beds and a 21-bed respiratory care
Women’s Wellness Center. In 2010, Northwest received
unit. The Specialty Hospital at Levindale consists of a 40the Silver Plus Award from the American Heart Association bed high intensity care unit and an 80-bed behavioral
and the Primary Stroke designation from the American
health unit. Levindale also has two adult medical day
Stroke Association. In 2011, the hospital’s Sub-acute Unit centers; an outpatient mental health clinic and a geriatric
was named a US News and World Report “Best Nursing
partial day hospital program. As a multi-denominational
Home.”
geriatric hospital and long term care facility, Levindale
offers a complete range of quality health care programs
Northwest Hospital completed its formal community
for the elderly and disabled.
health needs assessment as required and defined by the
Patient Protection and Affordable Care Act and Section
Levindale is a member of LifeBridge Health – a Baltimore501(r)(3) of the Internal Revenue Code during fiscal year
based health system composed of Sinai Hospital of
2016 (FY16).
Baltimore, Northwest Hospital, Carroll County Health
Services Corporation, and Levindale Hebrew Geriatric
Center and Hospital – and is a constituent agency of The
Overview of Levindale Hebrew Geriatric
ASSOCIATED: Jewish Community Federation of Baltimore.
Center and Hospital
Levindale Hebrew Geriatric Center and Hospital was
founded in Baltimore City in 1890 as the Hebrew Friendly
Inn and Aged Home, giving temporary shelter to the waves
of incoming Jewish immigrants fleeing persecution in
Europe.
In late 2015 – early 2016 Levindale completed a formal
community health needs assessment as required and
defined by the Patient Protection and Affordable Care Act
and Section 501(r)(3) of the Internal Revenue Code during
fiscal year 2016 (FY16).
THE CHNA PROCESS
The CHNA Team
The process used to identify health needs of LifeBridge Health’s community included analyzing primary and secondary
data at the community level and included public health experts, community members and key community groups in
further prioritization of concerns and needs. The CHNA Team is listed below and included a host of employees across
the LifeBridge Health system.
Employee Name
Department
Title
Karen Adams
Government Relations & Community Development
Administrative Assistant
Terrie Dashiell, RN
Office of Community Health Improvement (OCHI)
Program Manager
Ademola Ekulona
Community Initiatives
Program Supervisor
Joy Hall
Women’s Health Education
Community Health Educator
Sharon Demarest
Government Relations & Community Development
Coordinator
Sharon Hendricks
Patient Experience at Northwest Hospital
Director
Livia Kessler
Population Health
Operations Manager
Martha Nathanson
Government Relations & Community Development
Vice President
Israel (Izzy) Patoka
Government Relations & Community Development
Director, Community Development
Jacquetta Robinson
Population Health
Health Ambassador
Carmera Thomas
Strategic Marketing & Communications
Community Outreach Coordinator
Garrick Williams
Community Initiatives
Community Outreach Worker
Darleen Won
Population Health
Director
Pamela Young, PhD*
Independent Contractor
Consultant
Review of Public Health Data
The CHNA team used publicly available data sources from national, state and local government and private
organizations. This included the U. S. Census information from 2014, State of Maryland Vital Statistics from 2013, the
Baltimore City Health Department neighborhood profiles from 2013, and the Baltimore County Department of Health
CHNA completed in 2015. In order to supplement the public health data obtained from publicly available sources and
to complete the CHNA, the team engaged with local public health partners and community residents to gather input
from persons representing community interests. It is important to note the gap in time for available reported data.
The team relied on the sources mentioned previously to review back-dated reports to confirm accuracy of health
trending data. The CHNA team is working to identify more sources of current information for future reporting needs.
Engagement with Public Health Partners and Community Human Services Partners
LifeBridge Health, Inc., initiated early talks with both Baltimore City and Baltimore County Health Departments around
local health improvement plans to support the Maryland State Health Improvement Plan (SHIP). In summer 2015, a
representative of the CHNA team met with Baltimore City Health Department’s Chief of Epidemiology Services, Darcy
Phelan-Emrick, DrPH, MHS and the Director of the Office of Policy and Planning, Shannon Mace Heller, JD, MPH to
*LifeBridge Health utilized the services of an outside contractor for data collection and narrative production in regards to this CHNA report. The
contractor, Pamela Young, PhD, is a professional social worker who has developed and administered programs designed to enhance the capacity
of the health care system to attend to the psychosocial needs of patients and their families. Dr. Young has over 30 years of experience working to
reduce the impact of social determinants of health and has acted as the primary facilitator of the Sinai Hospital/Adventist Health Care partnership.
THE CHNA PROCESS
discuss recent health assessment updates to the 2011 citywide health assessment that resulted in the City’s Healthy
Baltimore 2015 report and Neighborhood Health Profiles. The Neighborhood Health Profiles1 represented the city’s
public health sector’s own assessment of community needs throughout Baltimore City.
Additionally, because LifeBridge Health hospitals are located in both Baltimore City and Baltimore County, members of
the CHNA team also met with the Public Health Nurse Administrator of the Baltimore County Health Department,
Laura Culbertson, RN, MSN, as well as the Baltimore County Deputy Health, Officer Della J. Leister, RN. The discussion
with Baltimore County focused on the County’s recently completed needs evaluation, its availability to the public and
potential programming that might be developed as a result of its findings.
Following LifeBridge Health’s 2012 CHNA and the partnerships developed with both the Baltimore City and County
Health Departments during that process, representatives of LifeBridge Health were invited to serve on the Local Health
Improvement Councils of both public health departments. Involvement in those councils by hospital staff kept communication between the public health sector and LifeBridge Health active and fostered increased collaboration during the
interval between the two CHNAs.
LifeBridge Health also continued and enhanced its routine practice of collaborating with community and human service
partners in order to facilitate community involvement and input during the community health needs assessment process. Key partners representing the community stakeholders include: representatives from Baltimore County Recreation & Parks, Park Heights Renaissance Center, Park Heights Community Health Alliance, Liberty Road Business Association, CHAI, Manna Bible Baptist Church and a County Executive Official. Other community partners that assisted during
the CHNA process or provide program support are identified in Section 6: LBH Resources and Partners. LifeBridge
Health representatives attended meetings of each partner organization and sought support from each to facilitate the
CHNA process. Assistance from partner organizations included spreading the word about the assessment, distributing
and collecting community surveys, providing space and allocating meeting time for gathering community input on
health needs and offering consistent support for other tasks as needed. In addition, partners contributed feedback
and participated in the prioritization of community health needs.
Prior to the completion of the community health needs assessment, LifeBridge Health also identified clinical and
community needs based on feedback from individual hospital departments. This practice continues and offers additional clinical input identifying and prioritizing needs. Clinical input is derived from the treatment of patients and interactions with both patients and their families or caregivers. For example, hospital departments providing community
benefit services continue to conduct routine assessments of patient and community needs resulting from day-to-day
experiences with population groups served by the hospital.
Data Collection: Surveys and In-person Feedback
In order to gather community input on health needs as well as stakeholder representatives, the CHNA team used a two
-pronged approach yielding both a written survey and in-person feedback session data.
Surveys
During the 2012 CHNA process, the CHNA team identified an existing survey tool created and used by Tanner Health
System (Carrollton, Georgia). With approval, the CHNA team adapted that survey to use in the Sinai CHNA in 2012 and
repeated its use again in 2015. The survey has a total of 19 questions, including 18 multiple choice questions and one
additional free response question to allow for feedback on the questionnaire and additional concerns (see Appendix
A). The first section of the survey asks questions about health concerns, barriers to seeking quality health care, community needs and health information sources. The second section asks eight demographic questions, including
THE CHNA PROCESS
gender, age, race, ethnicity, highest level of education and insurance status in order to capture a snapshot of the
survey respondents.
The CHNA team distributed paper surveys at community events, meetings and fairs, as well as in waiting rooms, lobbies
and communal spaces around various community sites within the LifeBridge Health primary service areas (PSA). Sites
included community centers, restaurants, pharmacies, places of worship, etc. The team also relied upon partners
to spread awareness about the survey as well as to distribute surveys for completion. All completed surveys were
returned to the CHNA team located at Sinai Hospital.
In total, 1,530 surveys were collected for the entire LifeBridge Health system. A single CHNA team conducted Sinai,
Levindale and Northwest Hospitals surveys, as all hospitals are in relatively close proximity and share certain PSA zip
codes. Sinai and Levindale are directly across the street from each other and thus share the same geographic
community in northwest Baltimore City and the bordering communities of Baltimore County; however due to the
unique nature of the patients utilizing Levindale, separate PSA’s were established and included from the state
regulatory body known as the Health Services Cost Review Commission (HSCRC). Hospital is situated further north and
west in Baltimore County. Due to this overlapping of Primary Service Area zip codes, the data analysis relied upon a
second level of decision-making to categorize survey responses as ‘Sinai, Levindale, or Northwest.’
When the survey respondent’s residence was indicated to be in one of the overlapping zip codes, the respondent’s
answer to the question ‘When seeking care, which [acute care] hospital would you visit first?’ became the tiebreaker
for categorizing responses from individuals living in a service area zip code shared by Sinai and Northwest Hospitals. If
that question was not answered, then the location where the survey was collected was the final means of attribution to
the appropriate hospital.
In-Person Feedback: Community Feedback Sessions
The CHNA team worked with local partners to participate in six face-to-face community feedback sessions. Feedback
sessions were open to the general public including residents and representatives from local community-based
organizations, places of worship, schools, etc. Community members and stakeholders learned about the feedback
sessions through a variety of mechanisms including paper flyer distribution, e-mail notices, event postings on
community calendars, announcements at community meetings and gatherings, and through word of mouth. Due to
the fact that the feedback sessions were scheduled to occur during regularly scheduled community meetings at partner
organizations, most participants heard about the meeting through attendance at previous meetings.
The feedback sessions were at least one hour in length. During each session, CHNA team members explained the CHNA
process thus far and the reason for the meeting. The facilitator on the CHNA team also reviewed the 2012 CHNA
outcomes and introduced the program managers of the two community health improvement projects that were
developed in response to the findings of the 2012 CHNA. Each program manager then gave a report on the program’s
purpose, development and outcomes to date. Following those presentations, the facilitator reported on 2015 survey
findings, asked participants for their opinions on what the surveys indicated and for input on how to prioritize and
address identified needs. Participants offered ideas for resources, partners and community health improvement
project strategies.
In order to prioritize community health needs, the CHNA team facilitated a multi-voting exercise at the community
feedback sessions. Each participant used three Post-It notes as their ballots for the health needs that they perceived to
be greatest. Participants were instructed to vote by placing the Post-It notes onto flip charts posted around the
meeting room. Each flip chart was labeled with a different health concern, which had been selected based on
preliminary survey results of the top 6 causes of death (survey question 1) and top 6 community health concerns
(survey question 2) identified by survey respondents. The CHNA team decided to present the six health conditions
THE CHNA PROCESS
representing either top cause of death or top health concern to meeting participants for the voting exercise. Participants were asked to place their three votes in any distribution, weighting any health concern with more than one vote,
if they wished; they could also submit write-in votes for health concerns not posted. Through this process of multivoting, the prioritization of health needs was clearly identified and endorsed by community stakeholders, partners,
and residents.
Community Feedback Sessions Schedule
Sinai Hospital of Baltimore and Levindale Hebrew Geriatric Center and Hospital:
Session One: The first community feedback session was held on October 20, 2015 from 6:00-7:00 pm during
the October general membership meeting of Neighborhoods United, a coalition of Park Heights community
associations. This meeting is held monthly in the Northwest Community Resource Center, a city-owned multipurpose center at 3939 Reisterstown Road, Baltimore, MD 21215. There were 35 community members present
at that meeting.
Session Two: The second community feedback session was held on October 23, 2015 from 12:30 – 1:30pm
during a regularly scheduled meeting of the Zeta Healthy and Active Aging Partnership (Z-HAP). The physical
location of the session was the Zeta Center for Healthy and Active Aging at 4501 Reisterstown Road, Baltimore,
MD 21215. 75 participants attended that meeting.
Session Three: The final community feedback session was held on October 28, 2015 from 7:00 – 9:00 pm at the
Manna Bible Baptist Church, 3043 W. Belvedere Ave., Baltimore, MD 21215. There were 30 community members present at that meeting as well as representatives from Manna Baptist Bible Church.
Northwest Hospital:
Session One: The first community feedback session was held on October 8, 2015 from 7:00-8:30 pm in the multi-purpose room of the Randallstown Community Center at 3505 Resource Drive, Baltimore, MD 21133. There
were 4 community members as well as County Executive were present at the meeting.
Session Two: The second community
feedback session was held on October
14, 2015 from 7:00-8:00 pm during a
regularly scheduled meeting of the Stevenswood Improvement Association at
a multi-purpose room in Northwest
Hospital, this organization’s customary
meeting location. There were 21 community residents at this meeting.
Session Three: The final community
feedback session was held on October
29, 2015 from 6:30-7:30 pm in the multi-purpose room of the Randallstown
Community Center at 3505 Resource
Drive, Baltimore, MD 21133. There
were 2 community members present at
that meeting.
Picture 1. Themes portrayed in a word cloud identified through CHNA 2015
process.
SINAI HOSPITAL OF BALTIMORE
Picture 2. Sinai Hospital referenced by the hospital marker is located within the
red and purple primary service areas on the map.
Sinai Hospital is located in the northwest quadrant of Baltimore City, serving both its immediate neighbors and others from throughout the Baltimore City and Baltimore County. The
community served by Sinai Hospital can be defined by its PSA and geographically represents
the zip codes immediately surrounding Sinai Hospital.
The PSA is comprised of zip codes from which the top 60% of patient discharges originate.
Listed in order from largest to smallest number of discharges for fiscal year 2014, Sinai Hospital’s PSA includes the following zip codes: 21215, 21207, 21208, 21209, 21117 and 21216 represented by the red and purple areas in Picture 2.
THE SINAI HOSPITAL COMMUNITY
Community Demographics and Public Health Data
When comparing community demographics to our survey respondents designations, the large sample size (n=921) and
comparable composition of characteristics provides justification that the sample is an appropriate representation of the
community and thus a reliable source for the needs assessment process (Table 1). Although the sample size has an
aging population compared to the general age distribution across the community, the age distribution is not surprising
considering the manner in which survey collection transpired. Responses from adults ages 18 and older have higher
validity and are considered more descriptive of the community LifeBridge will be able to affect through programming
and support.
Community Zip Code Demographic Quick Facts
2015 CHNA Survey
Respondents
Zip code: 21215, 21207, 21208, 21209, 21117, 21216
2015 Estimates used
Population
2010 Census: 253,870
2015 Estimate: 258,102
2020 Projection: 264,365
921 Respondents
Age
0-17 yr: 58,766 (22.8%)
18-64 yr: 157,701 (61.1%)
65 yrs. and older: 41,635 (16.1%)
0-17 yr: 17 (2%)
18-64 yr: 629 (68%)
65 yrs. and older: 275 (30%)
Households
2010 Census: 101,474
2015 Estimate: 102,998
2020 Projection: 105,474
N/A
Income
Income less than $15,000 (below FPL): 17,986 (14.6%)
Income between $15,000 to $34,999: 19,766 (19.2%)
Income between $35,000 to $74,999: 31,801 (30.9%)
Income between $75,000 to $99,999: 11,597 (11.3%)
Income over $100,000 or more: 24,847 (24.1%)
N/A
Gender
Male: 118,532 (45.9%)
Female: 139,570 (54.1%)
Male: 289 (31%)
Female: 536 (58%)
Did not respond: 96 (10%)
Race
White Alone: 76,384 (29.6%)
Black or African American Alone: 161,741 (62.7%)
American Indian and Alaska Native Alone: 661 (0.3%)
Asian Alone: 9,096 (3.5%)
Some Other Race Alone: 4,517 (1.8%)
Two or More Races: 5,702 (2.2%)
White Alone: 77 (8%)
Black or African American Alone: 758 (82%)
American Indian and Alaska Native Alone: 25 (3%)
Asian Alone: 8 (1%)
Some Other Race Alone: 7 (1%)
Did not respond: 46 (5%)
Ethnicity
Hispanic or Latino: 10,233 (4.0%)
Not Hispanic or Latino: 247,869 (96.0%)
Hispanic or Latino: 20 (2.0%)
Not Hispanic or Latino: 771 (84%)
Did not respond: 130 (14%)
Home Ownership
Owner-Occupied: 58,675 (57.0%)
Renter-Occupied: 44,323 (43.0%)
N/A
Education
Less than 9th grade: 7,002 (4.0%)
Some High School, no diploma: 15,359 (8.75%)
High School Graduate (or GED): 45,485 (25.91%)
Some College, no degree: 36,905 (21.0%)
College Degree: 43,256 (24.6%)
Master’s Degree or above: 27,513 (15.7%)
Some High School, no diploma: 151 (16%)
High School Graduate (or GED): 301 (33%)
Some College, no degree: 170 (18%)
College or Technical Degree: 154 (17%)
Master’s Degree or above: 73 (8%)
Did not respond: 72 (8%)
(Avg. Household Size:2.46;
Est. Median Household income:
$54,594)
Table 1. Community Quick Facts: Sinai Primary Service Area. Sitewise Online. (4/19/2016)2
THE SINAI HOSPITAL COMMUNITY
The racial composition and income distribution of these zip codes reflect the segregation and income disparity characteristics of the Baltimore metropolitan area. Those zip codes that have predominantly African American residents, including 21215 (Sinai Hospitals location), reflect the racial composition and poverty seen in Baltimore City. This is in contrast to neighboring Baltimore County zip codes (21209 & 21208) in which the median household income range is much
higher compared to Sinai Hospital’s larger patient population, and in which the residents are predominantly white.
Mortality Data: Baltimore City
Using data from the Maryland Department of Health and Mental Hygiene, Vital Statistics as well as the Baltimore City
Health Department Neighborhood Health Profiles ,the CHNA team explored chronic disease outcomes for Baltimore
City. The top cause of death for Baltimore City residents is heart disease, accounting for 23.5% of all Baltimore City
deaths in 2014. Diabetes followed as the fifth leading cause of death (accounting for 3.3% of all Baltimore City 2014
deaths. As referenced in Table 2, the mortality rate for the top 5 diseases is significantly higher within Pimlico/
Arlington (21215) as compared to Baltimore City, and both are higher than Baltimore County residents.
Health Status
Indicator
Life Expectancy At
Birth
Baltimore City
Pimlico/
Arlington
Baltimore County
2007-2009 2010-2012 2007-2009 2010-2012 2007-2009
70.9
71.8
65.6
2010-2012
66.8
78
79.2
Mortality Rate
(deaths per 10K population)
All Cause
113.9
110.4
147.2
135.3
79.7
73.7
Heart Disease
28.9
25.8
38
26.8
19.5
17.6
Cancer
23.4
20.8
26.1
18.9
18.7
17.4
HIV/Aids
5.2
3.5
8.6
4.8
0.6
0.3
Chronic Lower Respiratory Disease
3.9
3.5
4.3
3.9
4.0
3.5
Diabetes
3.7
3.5
5.4
3.8
2.0
1.8
Improve Health Status Indicators for our Communities
life expectancy/ mortality/ prenatal care/ birth weight/ childhood vaccinations/ flu & pneumonia vaccines/ graduation
rates/ obesity reduction/ smoking cessation/ chronic care populations with HbA1C <8% and blood pressure <130/80
mmHg
Table 2. Health Status Indicator Comparison Baltimore City, Pimlico Arlington, and Baltimore County. (Baltimore City Health
Department, Neighborhood Health Profiles, 2011.) 3
THE SINAI HOSPITAL COMMUNITY
Looking more closely at the geographic mapping of mortality within Baltimore City in Figure 1, the northwest swath
of the city has some of the strongest concentrations of high incidences of infant mortality, and the lowest life expectancies, compared to other communities neighboring the hospital. As depicted in Figure 1, Pimlico/Arlington and several of the neighborhoods south and west of the community have similar representations.
Figure 1. Baltimore City Life Expectancy by Community Service Area and Baltimore City mortality by Age (Less than 1 Year Old.
(Baltimore City Health Department, 2013.) 4
In addition to lower life expectancy, other social determinants of health characterize the community in which Sinai
Hospital is located. Low income levels, lower educational attainment, vacant housing, and high beer and liquor sales
are just a few of the social concerns faced by this community. In Figure 2, on the next page, the concentration of
adults on parole or probation and gun-related homicides indicate that the Sinai primary service area has significant
concerns around incarcerations and violence.
THE SINAI HOSPITAL COMMUNITY
Figure 2. Baltimore City Percent of the Adult Population that is on Parole or Probation and Baltimore City Rate of Gun-Related
Homicides. (Baltimore City Health Department, 2013.) 4
The 2013 Baltimore City Health Disparities Report Card notes a decrease in the overall mortality rate in Baltimore
City between 2000 and 2012, compared to the entire state of Maryland. However, Baltimore City still has a mortality rate 1.34 times that of the state. The Report Card evaluates the city’s progress in improving health and reducing
health disparities between certain groups compared to others based on geography (Baltimore City rates/Maryland
rates), race (non-Hispanic African American rates/ non-Hispanic White rates), gender (male rates/female rates), education (<high school rates/some college or >rates) and income (<$15,000 rates/≥ $75,000 rates). The report notes
that when assessing disparities, it is important to recognize that fluctuation in disparities can be the result of either
the improvement of one group or the decline in another. In the comparisons the report also compares the change in
disparities between 2008 and 2012, then assigns a letter grade (A-F) in each of several indicators on mortality, selfreported health status, self-reported healthcare, and self reported healthy homes and communities. In conclusion, a
final grade for each indicator was calculated using a median of all grades in the various comparisons for each indicator. The values and grades for the mortality indicators are shown in Table 3.
THE SINAI HOSPITAL COMMUNITY
Baltimore City Health Disparities Report Card
2013
Mortality
All-Cause
Cardiovascular
All-Cancer
Stroke
Diabetes
HIV/AIDS
Homicide
Median Disparity
1.13
1.11
1.44
1.14
1.45
Median Grade
B
B
C
B
C
4.87
8.71
F
F
Table 3. Baltimore City Health Department, Office of Epidemiological Services, Baltimore City Health Disparities Report Card,
2013. 4
In summary, the Disparities Report Card notes that despite improvements, there are still significant health disparities in
Baltimore City particularly, for residents with lower educational and income levels. In the two indicators signified by
failing grades— HIV/AIDS and homicide, African American males fare the worst. African Americans also had poorer outcomes in prevalence of diabetes and obesity rates as indicated in the complete Disparities Report Card. These are important disparity factors when considering the health of residents of Sinai’s primary service areas, which is characterized by large numbers of African American residents who have lower income and less educational achievement compared to Baltimore City as a whole.
SURVEY RESULTS & IMPLEMENTATION
The top 5 responses at Sinai Hospital for the questions relating to Top Cause of Death presented during the 2015 Community Health Needs Assessment survey are summarized below in Chart 1. These responses represent more than
70% of the 921 participant’s responses to Sinai’s survey. Of the 899 respondents who answered the question “What
do you think causes the most deaths in your community?”, 30% answered ‘violence’ followed by substance abuse
(16%), cancer (15%), heart disease (12%), diabetes (11%) and HIV/AIDS (8%).
Chart 1. Top 5 Sinai Hospital Survey Response: “What do you think causes the most deaths in your community?” CHNA 2015, LifeBridge Health.
Figure 3 below shows true mortality data for the top 5 causes of Baltimore City. Compared to the survey respondents’
perception of the top 5 causes of death , public health data identifies cancer, heart disease and diabetes as the primary causes of death. Community survey responses around perceived risk focused on violence and substance abuse,
reflecting the frustrations of a community entrenched in poverty.
Mortality Rates vs. Community Perception
Top 5 Cause of Death
Baltimore City
Community Survey (n = 899)
1
Heart Disease
23.5
Violence
30%
2
Cancer
21.8
Substance Abuse
16%
3
Stroke
5.2
Cancer
15%
4
Accidents
1.6
Heart Disease
12%
5
Diabetes
3.3
Diabetes
11%
* Morality rate = deaths per
10,000
% of total respondents
Figure 3. Mortality Rates of Baltimore City compared to Community Perception for Top 5 Causes of Death from the 2015 CHNA
respondents. (Baltimore City Health Department, 2013.) 4
SURVEY RESULTS & IMPLEMENTATION
In addition to identifying the ‘top cause of death,’ we asked respondents to select their ‘biggest health concern’ from a
provided list. Of the 888 respondents who answered the question “What do you think is the biggest health concern in
your community?”, 27% chose drug/alcohol abuse followed by violence (14%), cancer (11%), HIV/AIDS (11%), and diabetes (10%). (Not pictured is heart disease (6%), the 6th biggest health concern of community respondents.)
Chart 2. Top 5 Sinai Hospital Survey Response: “What do you think is the biggest health concern in your community?” CHNA
2015, LifeBridge Health.
Comparing both key indicator questions, Sinai respondents identified similar themes to those at the partnering LifeBridge Health institutions later discussed within this report. The major concerns include chronic diseases such as
heart disease as well as diabetes. The survey responses also showed an overwhelming need to address the violent
atmosphere which has plagued the community and Baltimore City over the past year. The aftermath of the April 2015
Baltimore riots are captured by the survey responses across LifeBridge Health’s CHNA collectively. It should be noted
that most surveys were collected a mere 3 months after this event. This acute awareness, as well as the perception
of violent actions and individuals, has raised concern for safety, while increasing the potential for discrimination and
negative impact already experienced by these communities.
Additional Survey Results
The survey also included questions related to the respondents’ perceptions about barriers to seeking medical treatment and other factors that impact the quality of care community members receive, including their own health literacy and ability to access and use existing health care resources. There was also an overwhelming request for the hospital to offer screenings and educational information to the community through a variety of settings. Table 4 depicts
information from Sinai’s survey respondents when they were directed to select the top three screening and educational services that they felt would help address the health concerns of the community.
SURVEY RESULTS & IMPLEMENTATION
Table 4 shows the top five selections of respondents: blood pressure screenings, HIV/sexually transmitted diseases
screening and education, diabetes education, mental health screening and education, as well as heart disease and
stroke education. Overall, community education and screening services were identified as a common theme from
direct survey responses, as well as from participants in the community feedback sessions.
SHB
Question 5. “What health screenings or education
services are needed in your community?”
# of Responses
% of Total Responses
Blood pressure
481
52%
HIV/Sexually transmitted diseases
450
49%
Diabetes
437
47%
Mental health
Heart disease and stroke
435
398
47%
43%
Cancer
384
42%
Dental health
Nutrition
347
313
38%
34%
Cholesterol
Physical activity
300
291
33%
32%
Table 4. Sinai Hospital Survey Response: “What health screening or education services are needed in your community?” CHNA 2015,
LifeBridge Health.
Community Feedback Sessions Results
In addition to recording community feedback session participants’ answers to questions about community health and
needs, the facilitator asked participants to prioritize community health needs by use of the multi-voting method described previously. The results are as follows:
Violence = 107 votes
Substance abuse = 30 votes
HIV/AIDS = 24 votes
Diabetes = 23 votes
Cancer = 23 votes
Heart disease = 22 votes
Mental health = 20 votes
The CHNA team evaluated results from surveys, community input sessions, and public health data to arrive at the top
community health needs indicated by these sources. Additionally the CHNA team made an assessment of hospital
planning, initiatives, expertise and capacity to determine top health needs to be addressed by the implementation
strategy. The team, in consultation with the Director of Population Health— the department charged with implementation of community health improvement projects— arrived at the decision to focus on ‘VIOLENCE’ the top prioritized
need by community feedback session participants and survey response. The team also decided to continue to focus on
‘HEART DISEASE and DIABETES’ for the hospital’s community health improvement projects (CHIPs) and expand services to accommodate more participants.
SURVEY RESULTS & IMPLEMENTATION
Prioritized Needs: Sinai Hospital
Violence
Violence was the leading cause of death according to survey respondents. Violence also ranked as the 2nd top health concern.
In community feedback sessions, participants prioritized violence
as the top health concern that requires action.
During the 2012 CHNA, the problem of street violence in the Park
Heights community arose as a significant community health concern, especially during the community feedback sessions. In response to that concern, Sinai’s Community Initiatives department
developed the Kujichagulia Center, a youth mentoring, violence Picture 3. Garrick Williams with participants of the
prevention and intervention program (see Appendix B for ProKujichagulia Center.
gress Report). Community responses indicated that this issue is
even more urgent in 2015 than during the last CHNA.
Heart Disease and Diabetes
Heart disease and diabetes account for 23% of survey respondents on leading causes of death, and 16% of respondents on health concerns. Also, in community feedback sessions, both heart disease and diabetes together received the
.
second greatest number of responses as a top health concern.
Survey respondents perceived heart disease as the fourth leading cause of death and sixth top health concern in their
community, and diabetes as the fifth leading cause of death and fifth top health concern. Community feedback session participants prioritized diabetes as their community’s fourth health need followed by heart disease as the sixth.
Following the 2012 CHNA, Sinai developed a health improvement project to address and prevent the cluster of heart
disease-related conditions including diabetes, high blood pressure, stroke, obesity, etc. Similarly, the Baltimore City
Health Department, in its 2013 Health Disparities Report Card, expanded its definition of mortality from heart disease
to include all cardiovascular mortality, incorporating, “. . . deaths from diseases of the heart, cerebrovascular disease,
and hypertension/hypertensive kidney disease.” LifeBridge Health’s program, Changing Hearts, was initiated in 2013
and will expand in response to the needs prioritized during the 2015 CHNA (see Appendix C for Progress Report) to
provide more education and community outreach.
According to the American Heart Association11, two out of three individuals with diabetes die from heart disease or
stroke; therefore, the prevention and treatment of diabetes is a step towards reducing the incidence and mortality of
cardiovascular disease and stroke. Changing Hearts focuses on reducing risk factors for cardiovascular disease such as
poor diet and limited physical activity, important components of any cardiovascular health improvement plan.
Sinai Hospital recognizes that not all identified community needs can be addressed and that difficult choices must be
made to properly allocate limited resources to the areas of greatest need. In addition, participants who require more
intense diabetes monitoring and follow-up are provided with a connection to the existing Sinai Hospital’s Diabetes
Medical Home Extender Program. Fortunately, the results of the community health needs assessment reveal that Sinai Hospital’s services are already well aligned with the prioritized community health needs that were not selected as
the focus of the CHIPs.
SURVEY RESULTS & IMPLEMENTATION
Needs not addressed within implementation strategy: Sinai Hospital
Alcohol/Substance Abuse and Behavioral Health
The CHNA’s finding that drug and alcohol abuse is a top community health need in Sinai’s surrounding community is
not a new concern. Indeed, Sinai has endeavored to respond to this need through the services of Sinai Hospital’s
Addictions Recovery Program (SHARP), an outpatient substance abuse treatment program that has provided treatment
services to opiate-addicted patients for over 20 years. SHARP’s mission is to serve the uninsured and under-insured
individuals who are opioid-dependent in Baltimore City.
SHARP currently has 350 treatment slots to serve many individuals at any one time. Through this program, medication
assisted treatment utilizing methadone is provided to patients 18 years of age and older. SHARP uses a comprehensive
model of treatment that combines methadone maintenance with the following services including: individual, group and
family counseling; substance abuse education for patients and families; primary medical care (assessment and referral)
for uninsured patients until connected with a provider; fully integrated dual diagnosis services for patients with coexisting psychiatric disorders; on-site testing and counseling for HIV and sexually transmitted diseases; and linkages
with adjunctive services as needed.
Sinai’s Department of Psychiatry is currently working closely with the Population Health department to implement
LBH’s population health strategy for those with behavioral health needs. This includes several strategies to improve
care coordination for patients with behavioral health care needs and ensure that all patients with such needs are
appropriately screened, diagnosed, referred to treatment, and monitored for compliance with treatment
recommendations and recovery.
In 2016 Sinai will standardize behavioral health screening and referral processes within the primary care setting,
starting with an evidence-based depression screening tool that is commonly used in the primary care setting, the
Patient Health Questionnaire (PHQ)-9. This will then be followed by a phased approach to integrate other screening
tools to support other mental health needs. These include: the Generalized Anxiety Disorders (GAD)-7 tool, an
evidence-based screening tool for anxiety and the Alcohol Use Disorders Identification Test (AUDIT) and Drug Abuse
Screening Test (DAST), versions 10, evidence-based tools to screen for alcohol and drug abuse. These tools are
currently used in Sinai’s behavioral health programs, but are not commonplace in other care settings. Sinai also plans
to establish pathways to appropriately follow-up on screening results to ensure that patients receive the care they
need, including intensive care external to Sinai if necessary.
In addition, Sinai’s plans include an enhancement to its behavioral health workforce to improve access to behavioral
health care services. This will include a Behavioral Health Navigation Team, consisting of social work, nursing, and
community health navigators, who will be integrated within primary care settings. The navigation team will be
responsible for:





Referrals to appropriate level of service
Resource coordination and assisting with barriers to access services
Tracking success of linkage to services and outcomes
Identifying needs and training office staff and providers on the referral processes to assist patients with
resources
Increasing patient engagement
Finally, Sinai has introduced telepsychiatry through a pilot in the Emergency Department during overnight hours, which
began in March 2016, thus providing patients 24/7 access to behavioral health care. The second phase of the pilot will
expand these services into the primary care setting with plans for full implementation for a broader patient population
by end of 2016 or early 2017.
SURVEY RESULTS & IMPLEMENTATION
Ultimately, Sinai will have integrated behavioral health care specialists available in our primary care offices, and plans
to link to the City of Baltimore’s developing behavioral health resources, including the Baltimore Crisis Referral and
Information line and the city-wide real-time Residential Capacity Assessment currently being designed to provide
accessible information for behavioral health providers across Baltimore.
Cancer
Cancer is the second leading cause of death in Baltimore City. Survey respondents selected ‘cancer’ as the third top
cause of death in their community, and the third biggest health concern. In community feedback sessions, participants
rated cancer as the fifth prioritized health concern.
The LifeBridge Health Alvin & Lois Lapidus Cancer Institute located at Sinai Hospital offers advanced specialized care in
all areas of cancer diagnosis and treatment. Cancer treatment centers and programs address the following conditions:
breast, gynecologic, hematologic, lung/thoracic, gastroenterological and urologic cancers, as well as bone, soft tissue
and endocrine tumors. In addition to diagnosis and treatment, the Institute provides supportive services and personal
development and enrichment opportunities for patients undergoing cancer treatment. Integrated therapies designed
to relieve anxiety and promote socialization include stress reduction techniques for patients and families, art
workshops, music therapy classes, guided imagery, meditation and chair yoga. Programs such as the American Cancer
Society’s Look and Feel Better Program, which provides makeup demonstrations, skin care therapies and special
products, are also available to patients.
In addition, the Institute also provides outreach and screening services to its communities, in an effort to raise
awareness to certain cancer risks and provide secondary prevention for those whose cancer may be found through
screening. The Freedom to Screen program at Sinai’s sister hospital, Northwest Hospital in nearby Baltimore County,
provides community outreach, breast cancer education, screenings and exams, mammograms, and follow-up
diagnostic procedures for lower-income, uninsured and under-insured women in both hospitals’ catchment areas (e.g.
Baltimore County and City). The goal of the program is to provide women with the resources they need to increase
breast cancer awareness and prevention. Additional assistance is offered to women who need help with patient
navigation services. Patient navigators help women who have received a breast cancer diagnosis deal with their
medical fears and develop a road to recovery.
In November 2015 LifeBridge Health implemented a Lung Cancer Screening Program, targeted to certain high risk
smokers, those ages 55-74 years of age who smoked either a pack a day for 30 years or more, or two packs a day for 15
years or more. Those eligible for the program receive a lung cancer screening using CT scanning. If there is a positive or
abnormal finding, a nurse navigator helps guide the patient through the process of selecting physicians, understanding
treatment plans, and communication with the primary care physician.
HIV/AIDS
HIV/AIDS is among the community’s top health concerns identified through the CHNA. This need is being addressed by
current hospital programming both for primary and specialty medical care through the hospital’s Infectious Disease
Ambulatory Clinic (IDAC) and for psychosocial needs through Community Initiatives HIV Support Services.
The IDAC serves HIV+ adults in a comprehensive medical setting with attention to patients’ primary medical care as well
as specialty services for HIV infection needs. The HIV Support Services program began in 1989 and addresses the social
and economic barriers that impact the health and well-being of individuals and families affected by HIV. Sinai’s HIV
Support Services is more robust than typical HIV support or “case management” services in that it serves several
groups simultaneously: women with children, women of childbearing age, pregnant women, infants, children, and
youth, a growing number of women of menopausal/post-menopausal age, and men. Services are provided by clinical
social workers and community health workers who use interventions which enhance access to care and facilitate
integration of medical and psychosocial services.
SURVEY RESULTS & IMPLEMENTATION
The overall goal is to improve HIV+ persons’ health by enhancing access to and utilization of care, and enhancing
emotional and social well-being through psychosocial support and counseling. By utilizing a comprehensive familyfocused approach, HIV Support Services in partnership with the IDAC’s medical services provide a continuity of care
unparalleled at other local hospitals.
NORTHWEST HOSPITAL
Picture 4. Northwest Hospital referenced by the hospital marker is located
within the blue and purple primary service areas on the map.
Northwest Hospital is located in the northwest quadrant of Baltimore, in the Randallstown
community of Baltimore County, serving patients throughout the Baltimore City and Baltimore County regions. The community served by Northwest Hospital can be defined by Northwest Hospital’s PSA, represented as the zip codes immediately surrounding Northwest Hospital.
The PSA is comprised of zip codes from which the top 60% of patient discharges from the hospital originate. Listed in order from largest to smallest number of discharges for fiscal year
2014, Northwest Hospital’s PSA includes the following zip codes: 21117, 21133, 21136, 21207,
21208, and 21244 represented by the blue and purple areas in Picture 4.
THE NORTHWEST HOSPITAL COMMUNITY
Community Demographics and Public Health Data
When comparing community demographics to our survey respondents designations, the sample size (n=564) and comparable composition of characteristics represented by the survey respondents align with the community (see Table 5).
The survey sample was older than the general age distribution across Northwest’s service area, as well as had higher
percentages of females, African Americans, and college educated respondents. Due to the method of survey collection,
the sample was not randomized and responses were considered in conjunction with community feedback sessions as
appropriate to represent the collective response from the community. Responses from adults ages 18 and older have
higher precedence and are considered more descriptive of the community LifeBridge will be able to affect.
Community Zip Code Demographic Quick Facts
2015 CHNA Survey
Respondents
Zip code: 21117, 21133, 21136, 21207, 21208, and 21244
2015 Estimates used
Population
2010 Census: 231,908
2015 Estimate: 240,740
2020 Projection: 250,445
564 Respondents
Age
0-17 yr: 54,451 (22.6%)
18-64 yr: 151,527 (62.9%)
65 yrs. and older: 34,760 (14.4%)
0-17 yr: 6 (1.0%)
18-64 yr: 387 (68.0%)
65 yrs. and older: 171 (31.0%)
Households
2010 Census: 91,645
2015 Estimate: 94,521
2020 Projection: 98,039
N/A
Income
Income less than $15,000 (below FPL): 8,265 (8.7%)
Income between $15,000 to $34,999: 14,247 (15.1%)
Income between $35,000 to $74,999: 30,462 (32.2%)
Income between $75,000 to $99,999: 13,184 (14.0%)
Income over $100,000 or more: 28,363 (30.0%)
N/A
Gender
Male: 111,298 (46.2%)
Female: 129,442 (53.8%)
Male: 153 (27%)
Female: 376 (67%)
Did not respond: 35 (6%)
Race
White Alone: 78,218 (32.5%)
Black or African American Alone: 138,525 (57.5%)
American Indian and Alaska Native Alone: 683 (0.3%)
Asian Alone: 11,153 (4.6%)
Some Other Race Alone: 5,445 (2.3%)
Two or More Races: 6,715 (2.8%)
White Alone: 107 (19%)
Black or African American Alone: 410 (72%)
American Indian and Alaska Native Alone: 7 (1%)
Asian Alone: 14 (3%)
Some Other Race Alone: 3 (1%)
Did not respond: 23 (4%)
Ethnicity
Hispanic or Latino: 13,176 (5.5%)
Not Hispanic or Latino: 227,565 (94.5 %)
Hispanic or Latino: 17 (3%)
Not Hispanic or Latino: 478 (85%)
Did not respond: 69 (12%)
Home Ownership
Owner-Occupied: 58,426 (61.8%)
Renter-Occupied: 36,095 (38.2%)
N/A
Education
Less than 9th grade: 5,371 (3.3%)
Some High School, no diploma: 8,822 (5.4%)
High School Graduate (or GED): 38,968 (23.7%)
Some College, no degree: 35,610 (21.7%)
College Degree: 47,802 (29.1%)
Master’s Degree or above: 27,664 (16.9%)
Some High School, no diploma: 94 (17%)
High School Graduate (or GED): 7 (1%)
Some College, no degree: 23 (4%)
College or Technical Degree: 267 (50%)
Master’s Degree or above: 110 (20%)
Did not respond: 30 (5%)
(Avg. Household Size: 2.5 ;
Est. Median Household income:
$67,374)
Table 5. Community Quick Facts: Northwest Primary Service Area. Sitewise Online. (4/19/2016) 2
THE NORTHWEST HOSPITAL COMMUNITY
Baltimore County residents, resources, socio-economic status, as well as neighborhood composition is very different,
than that of residents living within Baltimore City2. Although LifeBridge Health’s two hospitals share a few zip codes
( 21207 and 21208) the resources available to community members varies once crossing the city/county line. Baltimore County residents’ median household income range is higher than that of city residents and county neighborhood
composition has a higher concentration of Whites. Baltimore County has also experienced a steady increase in population growth over the past couple of years and future growth of the population aged 65 and over is expected to grow
significantly faster than other age cohorts according to the Baltimore County Department of Health. This growth will
impact resources and services, by creating a higher demand for services geared towards the aging Medicare population. Northwest Hospital plans to consider this impact for future program and needs alignment with our communities.
As identified by the Baltimore County Department of Health’s 2014-2015
Community Health Needs Assessment5, the County demonstrates positive
findings in maternal and child health findings as well as the adult population. Northwest Hospital’s PSA is associated more closely with Districts 2
and 4 (see Picture 5). As noted in the County Health Departments findings,
“District 2 has good rates for indicators related to the health of children
and access to health care… District 4 has good rate measures associated
with incidence of adult chronic diseases.” (Baltimore County Department
of Health, 2014-2015 CHNA.)
Mortality Data: Baltimore County
Overall, Baltimore County has higher life expectancies and lower mortality
rates than Baltimore City for all cause as well as disease specific indicators.
Using data from the Maryland Department of Health and Mental Hygiene
and Vital Statistics the CHNA team explored chronic disease outcomes for
Picture 5. Baltimore County District Map.
Baltimore County. The leading cause of death for Baltimore County (as a
(Baltimore County Department of Health 2014whole) compared to Maryland is diseases of the heart followed by cancer
2015 Community Health Needs Assessment).
(See Table 6 below).
Disease State
Baltimore County Maryland
Diseases of the heart
25%
25%
Cancer
22%
23%
Cerebrovascular disease
6%
5%
Chronic respiratory diseases
5%
4%
Accidents
4%
4%
Diabetes mellitus
2%
3%
All other causes
36%
36%
Table 6. Leading Cause of Death. (Maryland Department of Health and Mental Hygiene, 2013 Vital Statistics Reports.) 6
THE NORTHWEST HOSPITAL COMMUNITY
Due to the geographic size of Baltimore County, the local Health Department utilized a tool to index localized health
needs within the districts of the county. This tool, Community Need Index (CNI) developed by Dignity Health and
Truven Health Analytics, identifies the severity of health disparity at the zip code level, linking community need, access
to care and healthcare utilization as the index. In Picture 6, the red indicates the areas of highest need. The districts
that include Northwest Hospital service areas are included as areas with highest need. The Baltimore County Health
Department has identified focus areas for improvement for each of its districts.
Picture 6 . Community Need Index (CNI) for Baltimore County. (2016) 7
District two, represents 13% of Baltimore County’s total population. As one of two Northwest PSA County
jurisdictions, District two’s opportunities for improved health outcomes include programming related to cardiovascular
health and obesity/diabetes. District four, represents approximately 15% of Baltimore County’s total population. The
Baltimore County Health Department identified this district as having the largest racial class of African Americans as
well as being the second fastest growing district in the County. Areas identified for improved health outcomes in this
district include HIV/AIDS, prenatal health and education, and health-related education sessions.
In conclusion, Northwest Hospital’s primary service areas straddle the Baltimore City and Baltimore County lines,
drawing a geographic as well as socio-economic status divide. Compared to Sinai Hospital’s communities, the higher
median income, greater proportion of family households, as well as increased racial representation from the White
demographic align with differences in needs identified by the community and by the CHNA team.
SURVEY RESULTS & IMPLEMENTATION
The top five responses at Northwest Hospital for the questions relating to the “Top Cause of Death” presented during
the 2015 Community Health Needs Assessment survey are summarized below in Chart 3. These responses represent
more than 85% of the 564 participants responses associated with Northwest’s survey. Of the 557 respondents who
answered the question “What do you think causes the most deaths in your community?” the rankings in order of largest percentage to least percentage include: heart disease (32%), cancer (25%), violence (13%), diabetes (11%), and substance abuse (5%).
Chart 3. Top 5 Northwest Hospital Survey Response: “What do you think causes the most deaths in your community?” CHNA 2015, LifeBridge Health.
Gathering information obtained from surveys and at feedback sessions with public health data, yielded heart disease and cancer as top conditions causing death, which aligns with previous Baltimore County findings (see Table
6). It is important to consider the external factors that could have influenced the survey respondents during the
LifeBridge Health 2015 CHNA process, specifically factors relating to violence. After a series of highly publicized
national events, one occurring within Baltimore City less than 10 miles away from Northwest Hospital, paired with
daily reporting of increasing numbers of homicides within Baltimore, the response of violence as one of the top 5
causes of death, incorporates bias that was taken into consideration by the CHNA team. The topic of violence and
the opportunity for the hospital to address this issue was discussed throughout the community feedback sessions
at length. Many stakeholders within these sessions, considered the prioritization of violence from the surveys to
be part of the heightened awareness of the community and felt that prevention and management of chronic illnesses was more important for the hospital to address.
SURVEY RESULTS & IMPLEMENTATION
In addition to identifying the ‘top cause of death,’ we asked respondents to select their ‘biggest health concern’ from a
provided list. Of the 555 respondents who answered the question “What do you think is the biggest health concern in
your community?” 20% chose cancer, followed by diabetes (17%), drug and alcohol abuse (16%), heart disease (13%),
and violence (8%).
Chart 4. Top 5 Northwest Hospital Survey Response: “What do you think is the biggest health concern in your community?” CHNA
2015, LifeBridge Health.
Additional Survey Results
The survey also included questions related to the respondents’ perceptions about barriers to seeking medical
treatment and other factors that impact the quality of care community members receive, including their own health
literacy and ability to access and use existing health care resources. There was also an overwhelming request for the
hospital to offer screenings and educational information to the community through a variety of settings. Table 7
depicts information from Northwest’s survey respondents when they were directed to select the top three screening
and educational services that they felt would help address the health concerns of the community. The top five
selections from respondents includes: blood pressure screenings, heart disease and stroke prevention and education,
diabetes, cancer, and mental health screening and education. Overall, community education and screening services
were identified as a common theme from direct survey responses, as well as from participants in the community
feedback sessions.
SURVEY RESULTS & IMPLEMENTATION
Question 5. “What health screenings or education
services are needed in your community?”
NWH
Blood pressure
Heart disease and stroke
Diabetes
Cancer
Mental health
Cholesterol
Dental health
# of Responses
351
310
309
272
249
241
234
% of Total Responses
62%
55%
55%
48%
44%
43%
41%
HIV/sexually transmitted diseases
Nutrition
Physical activity
210
207
202
37%
37%
36%
Table 7. Northwest Hospital Survey Response: “What health screening or education services are needed in your community?” CHNA
2015, LifeBridge Health.
Community Feedback Sessions Results
In addition to recording community feedback session participants’ answers to questions about community health and
needs, the facilitator asked participants to prioritize community health needs by use of the multi-voting method described previously. The results are as follows:
Diabetes – 20 votes
Heart disease – 19 votes
Cancer – 19 votes
Mental health – 11 votes
Substance abuse – 3 votes
HIV/AIDS – 3 votes
Northwest’s survey respondents perceived heart disease as the leading cause of death and the fourth leading health
concern in their community. Diabetes was perceived as the fourth highest cause of death and the second highest as
the top health concern in their community. The community feedback session participants prioritized diabetes as the
communities top health need followed closely by heart disease.
Upon evaluating the results from surveys, community input sessions and public health data, the CHNA team arrived at
the top community health needs indicated by those sources. Additionally the CHNA team made an assessment of hospital planning, initiatives, expertise and capacity to determine top health needs to be addressed by the implementation strategy. The team, in consultation with the Director of Population Health decided to continue to focus on
‘HEART DISEASE and DIABETES’ with the hospital’s CHIP, placing emphasis on community education and disease prevention.
SURVEY RESULTS & IMPLEMENTATION
Prioritized Needs: Northwest Hospital
Heart Disease and Diabetes
According to the American Heart Association 11, two out of three individuals with diabetes die from heart disease or
stroke; therefore, the prevention and treatment of diabetes is a step towards reducing the incidence and mortality of
cardiovascular disease and stroke. The CHNA team decided to continue to develop the previous health improvement
project Changing Hearts, developed following the 2012 CHNA to address and prevent the cluster of heart disease related conditions including diabetes, high blood pressure, obesity, etc.
The LifeBridge Health Office of Community Health Improvement, housed at Northwest Hospital, created the Changing
Hearts program to serve as a heart disease prevention screening program to address the risk factors above (see Appendix C). Changing Hearts focuses on reducing risk factors for cardiovascular disease such as providing education on
the risk factors, improving poor diet habits, as well as increase participants physical activity. The program provides
screening for heart-related issues with follow up nursing and community health worker home visiting, telephonic follow-up and group classes. As an identified key priority for the Northwest community, LifeBridge Health will continue
to expand the program to increase participation and awareness of the risk factors that can lead to heart disease as
well as address the related conditions of diabetes and high blood pressure.
Changing Hearts Program featured in the LifeBridge Health Community Benefit Report, 2014. 15
SURVEY RESULTS & IMPLEMENTATION
Needs not addressed within implementation strategy: Northwest Hospital
Northwest Hospital recognizes that not all identified community needs can be addressed and that difficult choices must
be made to properly allocate limited resources to the areas of greatest need. Fortunately, the results of the
community health needs assessment reveal that services offered by Northwest as well as its parent organization,
LifeBridge Health, are well aligned with the following community health needs that were not selected as the focus of
the CHIP.
Cancer
Cancer is the second leading cause of death in Baltimore County and a significant health concern in the Randallstown
community surrounding Northwest Hospital according to survey respondents and feedback session participants. During
the feedback sessions in particular, participants cited cancer, specifically breast cancer, as both a top cause of death
and top health concern for which screenings and education was needed.
The LifeBridge Health Alvin & Lois Lapidus Cancer Institute offers advanced specialized care in all areas of cancer
diagnosis and treatment. Cancer treatment centers and programs address several disease conditions and provides
supportive services and personal development and enrichment opportunities for patients undergoing cancer
treatment. Integrated therapies designed to relieve anxiety and promote socialization are a few of the support services
provided across LifeBridge Health. The Freedom to Screen program at Northwest Hospital provides community
outreach, breast cancer education, screenings and exams, mammograms, and follow-up diagnostic procedures for
lower-income, uninsured and under-insured women in Baltimore County and City. The goal of the program is to
provide women with the resources they need to increase breast cancer awareness and prevention as well as offer
additional assistance to women who may need emotional support to deal with the new fears of a diagnosis and
develop a road to recovery.
Alcohol/Substance Abuse and Behavioral Health
The CHNA’s finding that drug and alcohol abuse is a top community health need in Northwest’s community was
consistent with concerns voiced by community residents during the 2012 CHNA process. Also at 2015 community
feedback sessions participants spoke about their concern over the need for mental health services and community
education to try to combat the bias and stigma against using such services.
LifeBridge Health’s Department of Psychiatry has expertise in serving those with behavioral health diagnoses and is
working with the Population Health department to integrate services in new settings to increase access for patients, as
well as providers to create an integrated system to better serve the population. Several strategies include identified
processes to improve care coordination for patients with behavioral health care needs and ensure that all patients with
such needs are appropriately screened, diagnosed, referred to treatment, and monitored for compliance with
treatment recommendations and recovery.
Ultimately, LBH aims to incorporate comprehensive quality of life assessment tools, in order to address the four
quadrants of health identified by the World Health Organization: physical, psychological, social relationships, and the
social determinants of health.12 As a system-wide approach, the hope is to incorporate plans for Sinai Hospital at the
sister hospitals to establish standardized pathways to appropriately follow-up on screening results to ensure that
patients receive the care they need, including intensive care external to Northwest if necessary.
As part of the care coordination described above, the use of technology is being piloted to share a limited resource
across multiple settings in order to provide access for patients in various settings. The telepsychiatry pilot is starting
within the emergency departments at Sinai and Northwest Hospitals in mid-March 2016. Through video-based
technology, patients (not in crisis but in need of psychiatric consults in the ED) will be able to use a web-based tool to
connect directly with providers. Initial findings of this technology show a huge increase in patient satisfaction for this
SURVEY RESULTS & IMPLEMENTATION
sub-population due to ease of use and accessibility of behavioral health providers. The second phase of the pilot will
expand these services into the primary care setting with plans for full implementation for a broader patient population
by end of 2016 or early 2017.
Violence
Based on Northwest survey respondents’ rankings, violence was the 5th highest health concern. However, feedback
session participants did not think it is such a major concern in Northwest Hospital’s communities but may be an artifact
resulting from the general anxiety about youth violence following the Baltimore uprising in April 2015.
In response to domestic violence concerns, Northwest Hospital has supported the long standing DOVE Program
(Domestic Violence Program) in order to provide support to victims of domestic violence. In 2015 the program was
recognized by the Maryland Network Against Domestic Violence (MNADV)13 and received the 2015 Lethality
Assessment Program Hospital Award in recognition for performance in yielding high level safety, counseling, support
services, and empowerment to people who may be in highly dangerous situations, providing nearly half of all lethality
assessment screenings at participating Maryland hospitals. DOVE provides 24/7 accessibility and has formally
connected with the Baltimore County and City law enforcement teams to provide support for those in the community,
not necessarily seen within the hospital.
LEVINDALE HEBREW GERIATRIC
CENTER & HOSPITAL
Picture 6. Levindale Hebrew Geriatric Center and Hospital referenced by the
hospital marker is located serves the yellow primary service areas on the map.
Levindale Hebrew Geriatric Center and Hospital (“Levindale”) is located in the northwest
quadrant of Baltimore City, serving both its immediate neighbors and others across the state
of Maryland. Levindale primarily serves the elderly, frail, and ill in need of skilled long-term
nursing, respite, dementia, respiratory, and comfort/hospice care. Due to the nature of the
services provided and the lack of availability across the state, the population served by
Levindale is not geographically representative of the community surrounding the hospital. .
Because Levindale’s patients’ zip codes vary widely, the CHNA team focused primarily on
21215, the zip code in which Levindale sits for which community health improvement projects are targeted.
For attribution purposes of the CHNA survey respondents, the CHNA team utilized the
HSCRC’s identified community benefit service area for the specialty hospital, indicated in Picture 5 as a primary service area. Listed in order from largest to smallest number of discharges for fiscal year 2014, Levindale’s PSA includes the following zip codes: 21211, 21212,
21218, 21221, 21222, 21228, 21229, 21286 represented by the yellow areas in Picture 6.
THE LEVINDALE HEBREW GERIATRIC
CENTER AND HOSPITAL COMMUNITY
Community Demographics and Public Health Data
When comparing community demographics to our survey respondents designations, the sample size attributed to
the CHNA for Levindale is small (n=45 respondents) and somewhat representative of the surrounding neighborhood
zip code (21215) in which Levindale is physically located (see Table 8). As described in the previous section, CHNA
team utilized information learned from the Levindale survey’s attributed as well as the results from the Sinai respondents, community feedback sessions, and public health data to review needs through the lens of elderly support and needs.
Community Zip Code Demographic Quick Facts
(US Census,2014 Estimates)
2015 CHNA Survey
Respondents
Zip code: 21215
Population
2014 Estimate: 63,764
45 Respondents
Age
0-17 yr: 16,075 (25.2%)
18-64 yr: 37,015 (58%)
65 yrs. and older: 10,673 (16.7%)
0-17 yr: 1 (2%)
18-64 yr: 35 (78%)
65 yrs. and older: 9 (20%)
Household Income Level
Income less than $15,000 (below FPL): 5,125 (22.5%)
Income between $15,000 to $24,999: 3,121 (13.7%)
Income between $25,000 to $49,999: 6,469 (28.4%)
Income between $50,000 to $74,999: 3,326 (14.6%)
Income between $75,000- $999,999: 2,118 (9.3%)
Income greater than $100,000: 2,619 (11.5%)
N/A
Gender
Male: 28,851 (45.9%)
Female: 34,912 (54.1%)
Male: 13 (29%)
Female: 31 (69%)
Did not respond: 1 (2%)
Race
White Alone: 9,566 (15%)
Black or African American Alone: 50, 717 (79.5%)
Asian Alone: 790 (1.2%)
Some Other Race Alone: 1,336 (2.1%)
White Alone: 10 (22%)
Black or African American Alone: 33 (73%)
Asian Alone: 0 (0%)
Some Other Race Alone: 3 (6%)
Ethnicity
Hispanic or Latino: 1,354 (2.1%)
Not Hispanic or Latino: 60,283 (97.9%)
Hispanic or Latino: 1(2%)
Not Hispanic or Latino: 40 (89%)
Did not respond: 4 (9%)
Education
Less than 9th grade: 2,594 (6%)
Some High School, no diploma: 6,571 (15.2%)
High School Graduate (or GED): 16,039 (37.1%)
Some College or Associates Degree: 8,906 (20.6%)
College Degree or above: 9,122 (21.1%)
Some High School, no diploma: 1 (2%)
High School Graduate (or GED): 10 (22%)
Some College, no degree: 11 (24%)
College Degree or above: 23 (51%)
Table 8. Community Quick Facts: Levindale Hebrew Geriatric Center and Hospital, 21215 US Census Data– Estimates 2014. 2
Levindale’s CHNA team further narrowed its ‘community’ definition from the entire 21215 zip code to the more
impoverished neighborhoods located below Northern Parkway and nearby Levindale and Sinai Hospitals, excluding
more affluent neighborhoods north of Northern Parkway. The neighborhoods, or community statistical areas
(CSAs), developed by the Baltimore City Planning Department, based on recognizable city neighborhood perimeters
and representative of clusters of neighborhoods based on census track data rather than zip code, constituting
Levindale’s community, are designated Southern Park Heights (SPH) and Pimlico/Arlington/Hilltop (PAH).
THE LEVINDALE HEBREW GERIATRIC
CENTER AND HOSPITAL COMMUNITY
Prior to the release of CSA boundaries, local residents referred to areas north of Northern Parkway, as ‘Upper Park
Heights’ and areas south of Northern Parkway as ‘Lower Park Heights. In this assessment, the broader term of ‘Park
Heights’ will be used synonymously with the combined area of SPH and PAH, just as it is used by community residents. Park Heights constitutes an area that is predominately African American with a below average median family
income, but above average rates for unemployment, and other social determinants of poor health.
Southern Park Heights (SPH) and Pimlico/Arlington/
Hilltop (PAH) represent six census tracts that make up a
Northwest Baltimore City area categorized as a
“medically underserved area/population designation” (MUA/P) according to the U.S. Department of
Health and Human Services14. This MUA/P received a
score of 48.80 out of 100 possible points on the Index of
Medical Underservice (IMU). The IMU is based on four
variables including infant mortality, poverty rate, age of
population, and rate of primary medical care physicians
per 1,000 population.
Picture 7. Levindale Hebrew Geriatric Center and Hospital,
21215 service area.
Mortality Data: Baltimore City
Using data from the Maryland Department of Health and Mental Hygiene, Vital Statistics the CHNA team explored
chronic disease outcomes for Baltimore City. The top cause of death for Baltimore City residents is heart disease,
accounting for 23.5% of all Baltimore City deaths in 2014, followed by cancer at 21.8% and cerebrovascular disease
(stroke) 5.2%. Diabetes followed as the fifth leading cause of death (accidents were fourth), accounting for 3.3% of
all Baltimore City 2014 deaths homicide was seventh with 2.9% of Baltimore City 2014 deaths.
The Baltimore City Health Disparities Report Card 4, 2013 (Table 3 from the Sinai report) also notes a decrease in
overall mortality rate in Baltimore City between 2000 and 2012, as in the state of Maryland, but that the city still
had a mortality rate 1.34 times that in the state. The Report Card evaluates the city’s progress in improving health
and reducing health disparities between certain groups compared to others based on geography (Baltimore City
rates/Maryland rates), race (non-Hispanic African American rates/ non-Hispanic White rates), gender (male rates/
female rates), education (<high school rates/some college or >rates) and income (<$15,000 rates/≥ $75,000 rates).
The report notes that when assessing disparities it is important to recognize that fluctuation in disparities can be the
result of either the improvement of one group or the decline in another. In the cumulative report an assigned letter
grade (A-F) represents the changes in disparities within each indicator. In conclusion the Disparities Report Card
notes that despite improvements, there are still significant health disparities in Baltimore City. These are for residents of lower educational and income levels, as well as in race and gender.
Health disparities are important factors when considering the health of residents of the Park Heights community,
which is characterized by large numbers of African American residents who have lower income and less educational
achievement than Baltimore City as a whole.
SURVEY RESULTS & IMPLEMENTATION
The top 5 responses at Levindale Hebrew Geriatric Center and Hospital for the questions relating to Top Cause of
Death presented during the 2015 Community Health Needs Assessment survey is summarized below in Chart 5. These
responses represent more than 70% of the 45 participants responses associated with Sinai’s survey. Of the 44 respondents who answered the question “What do you think causes the most deaths in your community?”, 43% answered
‘violence’ followed by cancer (21%), heart disease (14%), HIV/AIDS (7%), and diabetes (5%).
Chart 5. Top 5 Levindale Hebrew Geriatric Center and Hospital Survey Response: “What do you think causes the most deaths in
your community?” CHNA 2015, LifeBridge Health.
Figure 4 below shows true mortality data for the top 5 causes of death in Southern Park Heights, Pimlico/Arlington/
Hilltop and Baltimore City compared to the survey respondents’ perception of the top 5 causes of death. Respondents’
perceptions of the top cause of death were ranked 5th within the Park Heights neighborhoods CSA mortality rates,
most likely linked to heightened awareness of the social unrest within Baltimore City after the April rioting. It is important to note that the other conditions identified within the Park Heights neighborhood are in alignment with the
communities perception of top causes of death.
Mortality Rates vs. Community Perception
Top 5 Cause of Death
Southern Park Heights
Pimlico/ Arlington/ Hilltop
Baltimore City
Community Survey (n = 44)
1
Heart Disease
32.2
Heart Disease
34.7
Heart Disease
23.5
Violence
43%
2
Cancer
24.6
Cancer
24.0
Cancer
21.8
Cancer
21%
3
Stroke
7.3
HIV/AIDS
7.5
Stroke
5.2
Heart Disease
14%
4
HIV/AIDS
7.2
Stroke
6.0
Accidents
1.6
HIV/AIDS
7%
5
Homicide
7.0
Homicide
5.9
Diabetes
3.3
Diabetes
5%
* Morality rate = deaths per 10,000
% of total respondents
Figure 4. Mortality Rates of Baltimore City compared to Community Perception for Top 5 Causes of Death from the 2015 CHNA
respondents. (Baltimore City Health Department, 2013.) 3
SURVEY RESULTS & IMPLEMENTATION
In addition to identifying the ‘top cause of death,’ we asked respondents to select their ‘biggest health concern’ from a
provided list. Of the 45 respondents who answered the question “What do you think is the biggest health concern in
your community?”, 35% chose drug/alcohol abuse followed by diabetes (13%), heart disease (10%), violence (10%),
and cancer (8%).
Chart 6. Top 5 Levindale Hebrew Geriatric Center and Hospital Survey Response: “What do you think is the biggest health concern
in your?” CHNA 2015, LifeBridge Health.
Additional Survey Results
During community feedback sessions, there also was an overwhelming request for the hospital to offer screenings and
educational information to the community through a variety of settings. Table 9 includes information from Levindale’s
survey respondents who identified the top screening and educational services that would help address health concerns of the community.
LHGC
Question 5. “What health screenings or education
services are needed in your community?”
# of Responses % of Total Responses
Blood pressure
31
69%
Diabetes
28
62%
HIV/sexually transmitted diseases
27
60%
Dental health
24
53%
Heart disease and stroke
24
53%
Mental health
Cancer
23
21
51%
47%
Cholesterol
20
44%
Nutrition
20
44%
Eating disorders
17
38%
Vaccinations/immunizations
17
38%
Physical activity
16
36%
Table 9. Levindale Hebrew
Geriatric Center and Hospital Survey Response: “What
health screening or education services are needed in
your community?” CHNA
2015, LifeBridge Health.
SURVEY RESULTS & IMPLEMENTATION
The top five selections from respondents includes: blood pressure screenings, diabetes education, HIV and sexually
transmitted disease education, dental health screenings, and heart disease and stroke prevention and education.
Community education and screening services were identified as a common theme from direct survey responses, as well
as from participants in the community feedback sessions.
Community Feedback Sessions Results
In addition to recording community feedback session participants’ answers to questions about community health and
needs, the facilitator asked participants to prioritize community health needs by use of the multi-voting method
described previously. The results are as follows:
Violence = 107 votes
Substance abuse = 30 votes
HIV/AIDS = 24 votes
Diabetes = 23 votes
Cancer = 23 votes
Heart disease = 22 votes
Mental health = 20 votes
The CHNA team evaluated results from surveys, community input sessions and public health data to arrive at the top
community health needs indicated by those sources. Additionally the CHNA team made an assessment of hospital
planning, initiatives, expertise and capacity to determine top health needs to be addressed by the implementation
strategy. The team, in consultation with the Director of Population Health, the department charged with
implementation of community health improvement, arrived at the decision to focus on the ‘HEART DISEASE and
DIABETES’ education and prevention, as well as ‘VIOLENCE’ prevention support for the elderly for Levindale’s CHIPs
SURVEY RESULTS & IMPLEMENTATION
Prioritized Needs: Levindale Hebrew Geriatric Center and Hospital
Heart Disease and Diabetes
Survey respondents perceived heart disease as the third leading cause of death and third top health concern in their
community and diabetes as the fifth leading cause of death and second top health concern; community feedback
session participants prioritized diabetes as their community’s fourth health need followed by heart disease. Following
the 2012 CHNA, Levindale/Sinai developed a health improvement project to address and prevent heart disease-related
conditions including diabetes, high blood pressure, stroke, obesity, etc. (see Appendix C). Similarly, the Baltimore City
Health Department in its 2013 Health Disparities Report Card 4 expanded its definition of mortality from heart disease
to include all cardiovascular mortality, incorporating, “. . . deaths from diseases of the heart, cerebrovascular disease,
and hypertension/hypertensive kidney disease.” This program, Changing Hearts, was initiated in 2013 and will
continue in response to the need again prioritized during this CHNA.
The most frequent primary diagnoses of participants in the Levindale Adult Day Services included hypertension and
cerebrovascular disease. The structure of the program is ideal for new educational programming and routine
monitoring of cardiac health for patients and caregivers.
Healthy Baltimore 20159 identified the ‘promotion of heart health’ as a priority area. The plan seeks to decrease the
rate of premature deaths from cardiovascular disease by 10% and increase the percent of adults with high blood
pressure on medication by 10%. Risk factors for cardiovascular disease are also addressed in other priority areas such
as: Be Tobacco Free, Redesign Communities to Prevent Obesity and Create Health Promoting Neighborhoods. Park
Heights has been selected by BCHD as the target community for a pilot project around physical activity promotion.
Violence
In Park Heights, violence is consistently cited as a significant safety and community concern so its emergence as a top
health concern and top cause of death according to CHNA results is not surprising to those who live or work in Park
Heights. Results of the survey and feedback received during in-person community sessions revealed violence as a
significant problem facing the communities surrounding Levindale. For example, violence arose as the first leading
cause of death according to perceptions of community survey respondents. Violence also ranked as the 4th top health
concern.
As an institution primarily serving patients 55 or older, Levindale’s experience of ‘violence’ differs from that of Sinai
Hospital, a hospital with an Emergency Department and one of only four Level II Trauma Centers in the state of
Maryland. While Sinai Hospital focuses on manifestations of violence on the street, a result of the rampant drug trade
and gang presence in Park Heights, Levindale learned from its partner, THE ASSOCIATED, that a different form of
violence is affecting the Levindale patient community—elder abuse.
As our population ages, the number of Marylanders age 60 or above who are at risk for abuse are increasing. Over 15%
of the Maryland population is 60 or older. According to the 2010 National Elder Mistreatment Study10, one in 10
respondents in this age group (60+) reported abuse in the prior year, which translates into 80,000 Marylanders
experiencing abuse by a family member or caretaker every year.
The SAFE (Stop Abuse of Elders) project provides a bed for elder abuse victims in need of emergency shelter (see
Appendix D for Progress Report). This addresses the medical or level of care needs elder victims have in order to leave
their current abusive living situation. A member of the Levindale Social Work staff is dedicated to this project 5 hours
per week to work with SAFE participants when they are in shelter and to coordinate with community partners on plans
for return to the community.
SURVEY RESULTS & IMPLEMENTATION
Partnership with existing domestic violence programs at Northwest and Sinai Hospitals offers expert guidance in the
establishment of a domestic violence intervention service, and can refer age-eligible victims identified upon screening
in those hospitals’ emergency rooms or inpatient units. The Maryland State Health Improvement Plan (SHIP) identified
the reduction of domestic violence as a health priority. The plan also identified elder maltreatment as an emerging
issue in need of further research in order to understand trends, causes, and prevention strategies.
Needs not addressed within implementation strategy: Levindale
LifeBridge Health and Levindale recognize that not all identified community needs can be addressed and that difficult
choices must be made to properly allocate limited resources to the areas of greatest need. Fortunately, the results of
the community health needs assessment reveal that LifeBridge Health facilities provide existing services that are
already aligned with the following prioritized community health needs that were not selected as the focus of
community health improvement efforts. Due to the fact that Levindale does not provide acute care services and serves
a much older population compared to its sister hospitals, Sinai and Northwest, which provide acute care services and
serve a more age-diverse population, many responses to community health needs will be addressed at the systemlevel, involving the three LifeBridge Health hospitals involved in this CHNA.
Cancer
Cancer is the second leading cause of death in Baltimore City, Southern Park Heights and Pimlico/Arlington/Hilltop.
Survey respondents selected ‘cancer’ as the second top cause of death in their community, and the fifth biggest health
concern. In community feedback sessions, participants rated cancer as the fifth prioritized health concern.
The LifeBridge Health Alvin & Lois Lapidus Cancer Institute located at Sinai Hospital offers advanced specialized care in
all areas of cancer diagnosis and treatment. In addition to diagnosis and treatment, the Institute provides supportive
services and personal development and enrichment opportunities for patients undergoing cancer treatment. Programs
such as the American Cancer Society’s Look and Feel Better Program, which provides makeup demonstrations, skin
care therapies and special products, are also available to patients.
The Cancer Institute also provides outreach and screening services to its communities, in an effort to raise awareness
to certain cancer risks and provide secondary prevention for those whose cancer may be found through screening. In
November 2015 LifeBridge Health implemented a Lung Cancer Screening Program, targeted to certain high risk
smokers, those ages 55-74 who smoked a pack a day for 30 years or more, or two packs a day for 15 years or more.
Those eligible for the program receive a lung cancer screening using CT scanning. If there is a positive or abnormal
finding, a nurse navigator helps the patient negotiate the process of selecting physicians, understanding treatment
plans, and communication with the primary care physician.
Alcohol/Substance Abuse and Behavioral Health
The CHNA’s finding that drug and alcohol abuse is a top community health concern in the Park Heights community is
not new. Sinai has been well aware of the rampant drug abuse and trade in Park Heights and in Baltimore City
generally. Indeed, LifeBridge Health has endeavored to respond to this need through the services of Sinai Hospital’s
Addictions Recovery Program (SHARP), an outpatient substance abuse treatment program that has provided treatment
services to opiate-addicted patients for over 20 years. SHARP’s mission is to serve the uninsured and under-insured
individuals who are opioid-dependent in Baltimore City.
In addition, Levindale’s Outpatient Mental Health Center provides mental health therapies to individuals for the
purpose of stabilizing and maintaining chronic, or new-onset psychiatric/behavioral disorders, and providing an
effective follow-up plan that promotes well-being. Both programs focus on helping patients reach their maximum
functional level, enhancing their ability to live as independently as possible after discharge.
SURVEY RESULTS & IMPLEMENTATION
Comments expressed during community feedback sessions revealed community health concerns related to mental or
behavioral health. Levindale’s outpatient behavioral health services include a Partial Hospitalization Program (PHP) and
Outpatient Services (OPS) dedicated to providing effective, outpatient gero-psychiatric treatment to older adults
(usually 60 or older) who are experiencing behavioral or emotional difficulties. The OPS specifically targets those
individuals with a history of relapse and high utilization of psychiatric services. Both programs offer a brief (usually 30
treatment days or less) intensive, outpatient treatment as an alternative to acute psychiatric inpatient care. The most
frequent treatment interventions include group, individual and family therapies that promote optimal mental health
among a community of peers. Adjunctive treatment modalities may include medication management, assessments
(i.e. psychological, occupational and neurological testing) and behavioral management programming.
HIV/AIDS
HIV/AIDS is among the community’s top health needs identified through the CHNA. Although programming is not
specifically available at Levindale, services are provided at Sinai Hospital located directly across the street in the IDAC.
Psychosocial needs are met through Sinai’s HIV Support Services. The IDAC serves HIV+ adults in a comprehensive
medical setting with attention to patients’ primary medical care as well as specialty services for the HIV infection needs.
The HIV Support Services began in 1989 and addresses the social and economic barriers that impair the health and well
-being of individuals and families affected by HIV who seek medical services at Sinai. HIV Support Services is unique for
typical HIV support or “case management” services in that it serves several groups simultaneously: women with
children, women of childbearing age, pregnant women, infants, children, and youth, a growing number of women of
menopausal/post-menopausal age, and men. These services are provided by clinical social workers and community
health workers who use interventions that enhance access to care and facilitate integration of medical and
psychosocial services. The overall goal is to improve HIV+ persons’ health by enhancing access to and utilization of care,
and enhancing emotional and social well-being through psychosocial support and counseling. By utilizing a
comprehensive family-focused approach, the HIV Support Services in partnership with the IDAC’s medical services
provide continuity of care unparalleled at other local hospital sites.
Stroke (Complications)
In response the communities concern for those with stroke Levindale’s clinical services provide care for individuals who
present with complications from co-morbidities that have caused a stroke. For example, diabetic patients undergoing
amputation or stroke patients requiring specialized rehabilitation may be served by Levindale’s Rehabilitation Program.
The Rehabilitation Program consists of 20 comprehensive inpatient beds accredited by CARF [Commission on
Accreditation of Rehabilitation Facilities]. A comprehensive interdisciplinary team approach is provided for each
patient. The unit provides twenty-four hour care for patients who are able to tolerate at least three hours of
rehabilitation services a day. The most frequent diagnoses include post stroke patients, fractures, hip and knee
replacements, post amputation, other orthopedic related problems, respiratory comprised patients and traumatic
brain injured patients.
LBH RESOURCES AND PARTNERS
Consistent with the way LifeBridge Health works with community partners to provide community benefit services to its
patients and the community, our efforts addressing violence, heart disease, and diabetes require substantial support
and involvement from hospital-based and community partners.
The following hospital resources and partners aid in addressing violence and heart disease in Park Heights:
M. Peter Moser Community Initiatives
Vocational Services Program (VSP)
Sinai Hospital Ortho-Neuro-Trauma Units, Department of Surgery
Diabetes Resource Center at Sinai Hospital
Diabetes Medical Home Extender Program
The following human services and community-based organizations aid in addressing identified community
health needs related to the Kujichagulia Center’s violence intervention and prevention programming:
Baltimore City Community College
Family League of Baltimore
Jane Addams Resource Corporation (JARC) Baltimore
Mayor’s Office of Employment Development/Northwest Career Center
Neighborhoods United
New Vision Youth Services
North American Trade Schools
Baltimore City Police Department, Northwest Division
Park Heights Renaissance
Park West Health System, Inc.
Pimlico Road Youth Program
Safe Streets Park Heights
St. Vincent de Paul of Baltimore
Treatment Resources for Youth
University of Maryland Hospital Shock Trauma Violence Intervention Program
Wells Fargo Bank
LBH RESOURCES AND PARTNERS
The following human services and community-based organizations aid in addressing identified community
health needs related to Changing Hearts’ cardiovascular disease prevention efforts:
American Diabetes Association
American Heart Association
American Lung Association
American Stroke Association
Baltimore City Department of Recreation and Parks
Baltimore City Health Department
Maryland Department of Health and Mental Hygiene Office of Minority Health and Health Disparities
Baltimore City Department of Aging
Zeta Center for Healthy and Active Aging
West Baltimore Cares
Baltimore City Cardiovascular Disease Task Force
Park Heights Community Health Alliance
Baltimore City Board of Education
Baltimore City Head Start Program, St. Vincent DePaul of Baltimore
Park West Federally Qualified Health Center
Healthcare Access Maryland
Morgan State University School of Public Health
Johns Hopkins School of Public Health
Adventist Health Care
University of Maryland Horowitz Center of Health Literacy
Various businesses and church congregations within the Sinai, Northwest, and Levindale Hospital service areas
APPENDIX A. 2015 CHNA SURVEY
APPENDIX A. 2015 CHNA SURVEY
APPENDIX B. KUJICHAGULIA CENTER REPORT
Kujichagulia Center (KC) responds to the Park Heights community’s call for an end to Youth Violence by offering socalled “Opportunity Youth” (out-of-school, not in the Workforce, ages 18 to 25-years old) guidance and direction that
secures a viable future for today’s emerging adults (19- to 25-years old). This age group presents challenges and opportunities for the community because while they are leaving adolescence and its risk-hungry, fun-seeking irresponsibility, Inner City emerging adults often have little preparation for the demands of the working world where maturity
and self-control are pre-requisites to financial stabilization.
The 2012 CHNA revealed that Youth/Street Violence was a top priority concern of the Park Heights community. Sinai’s
Community Initiatives department responded to the community’s concern by establishing a Street Violence Intervention Pilot program (SVIP), supported by a grant from the Crane Foundation. Sinai Hospital Community Initiatives is a
member of the National Network of Hospital-based Violence Intervention Programs, which provided primary references for our violence intervention design.
At the time, Community Initiative's Youth Outreach Specialist reviewed daily the admissions to Sinai’s Trauma department to see if a patient meeting SVIP criteria had been admitted. The criteria are the following:




Resident of zip code 21215 at the time of being admitted
Male
19- to 24-years of age at time of admission
Patient is being treated for injuries sustained in street violence incidents (shooting, stabbing, cutting, assault) not related to domestic violence
In 2013, Community Initiative commissioned a consultant to review SVIP to make recommendations for its future.
While the Youth Outreach Specialist was diligent in screening Trauma admissions daily, he discovered that 1) relatively
few patients met all of the above criteria, i.e., most were from outside the 21215 zip code and 2) most were over the
24-year old age limit. When a patient meeting the criteria agreed to accept the offer of assistance in recovery, the
Youth Outreach Specialist felt he did not have much to offer the patient except referrals to local sources of various
types of assistance.
The consultant report suggested that Community Initiatives expand SVIP to serve patients treated at Sinai Hospital’s
Emergency Department and also focus on providing alternatives to violence processes and programs to fulfill the community’s express concern that they wanted to “…get the youth off the streets.” The consultant and Youth Outreach
Specialist also conducted three focus groups with Park Heights youth (males ages 16-18, 19-22, and 23-25) concerning
the kinds of things they felt would be effective activities that would engage youth. The overwhelming favorite was
“getting prepared for jobs so we can make money.”
When the opportunity arose to acquire funding for expanding SVIP, Community Initiatives submitted a proposal to the
Mayor’s Office of Human Services (MOHS) which was prepared to award funds from the so-called “Slots Money,” revenue from the establishment of casinos and slot machines in Maryland. The community within a one mile radius of Pimlico Race Track received major redevelopment funding under the Pimlico Community Development Authority. Park
Heights Renaissance was created to oversee redevelopment projects; the MOHS oversees the development of human
services programming, mainly targeting youth of Southern Park Heights.
Kujichagulia Center was awarded one of the first MOHS grants to implement its “alternatives to violence through selfdetermination” model involving Workforce Readiness and Working Life Skills for emerging adults (19- to 25-years old).
APPENDIX B. KUJICHAGULIA CENTER REPORT
Our collaboration partner at the time, New Vision Youth Services, provided Mentoring services while KC staff designed
and facilitated instructional activities for Workforce Readiness, Career Exploration, GED studies, and Life Skills for
Working People. We also assisted clients with obtaining what we call Social Identity—the paperwork (i.e., social security card, birth certificate, Maryland State I.D., etc.), reliable housing, proper clothing for job interviews and worksites,
establishing bank accounts, and health care coverage. Clients who are custodial fathers receive assistance dealing with
parenting and child care needs. We also assist young adults who are investigating colleges and trade schools for posthigh school career preparation.
Clients are offered opportunity to take part in the 5-week Workforce Readiness and Working Life Skills course. If they
complete course activities successfully, they receive a thorough (15 instruments) Career Assessment provided by Sinai’s Vocational Services Program (VSP) and if they pass a required physical exam and drug screening, they can engage
in an 8-week entry-level Internship at Sinai Hospital. Clients receive a $30.00 per 4-hour day stipend during the Workforce Readiness/Working Life Skills course and a $35.00 per 4-hour day stipend during the Internship.
Because KC is part of the multi-faceted social service programming available through Community Initiatives components, we are able to access a network of resources for referrals to meet client needs. We assist clients in maintaining
compliance with probation requirements, court appearances, and obtaining a lawyer, if necessary. Clients can also be
referred for mental health, substance abuse treatment, and housing assistance as need may occur. KC also benefits
from membership in the Park Heights Service Providers Network and the Safe and Supportive Park Heights Committee,
both of which provide access to other local programs that can serve as referral resources for our clients.
Staffing
Kujichagulia Center activities are carried out by a staff of three –
 Program Supervisor – oversees all programming and facilitates instructional activities, collaborations, and
VSP and 3rd-Party Internships as part of Workforce Readiness plans
 SVIP Interventionist – Contacts Trauma Unit and Emergency Department patients who are victims of violence to offer services and service coordination (case management).
 Youth Outreach Specialist – Conducts anti-violence focused mentoring sessions with 6th, 7th, and 8th grade
boys at KIPP Academy and Pimlico Elementary-Middle School; also serves as alternate SVIP Interventionist,
and Male Outreach Recruiter.
Looking Forward
The proposed implementation of the University of Maryland Hospital Shock Trauma Center Violence Intervention Program (STVIP) model would build upon what we’ve learned over the past three years. We know additional staff would
be required. Since the model would expand the age range of patients eligible for KC services and, possibly, expand the
eligible zip codes, we would need to expand staff in line with what is suggested in the proposal. The STVIP peer support
group functions are now occurring in the context of KC’s Workforce Readiness and Working Life Skills sessions.
KC has begun planning for direct linkage between our emerging adult (19 to 25 y.o.) clients and the Middle School boys
who receive Positive Male Youth Mentoring at KIPP Academy and Pimlico Middle schools. We will train the young
adults in the techniques and activities of the Alternatives to Violence project model so they can facilitate AVP sessions
with boys in the 6th, 7th, and 8th grades. In addition, we will host another Community Forum to give young people a
voice in conversation with leadership of key institutions. The Youths Vote Forum, to was held in March 2016, bringing
candidates from elected offices into dialogue with voters 18 to 25. The second Youth-Police Forum is scheduled for Fall
2016.
APPENDIX B. KUJICHAGULIA CENTER REPORT
Kujichagulia Center Preliminary Report Card (2014-2015)
Demographics
Education Status
Home Dynamics
# of Clients
Number of Active Clients
31
Average Age
21
High School Diploma
17
GED
2
Needing GED
10
Engaged in GED-studies
4
History in Foster Care
5
Father engaged with children
6
Single Custodial Fathers
2
Program Services Provided
Supported for legal help
9
Child custody resolution
3
Conviction record expungement
11
Parole compliance
5
Obtain vital records
5
Obtain driving permit
3
Obtain social security card
5
Obtain Maryland State ID card
5
Obtain temporary cash assistance award
3
Assistance with FAFSA application
2
Registered at Northwest Career Center
15
Referred for substance abuse services
4
Obtain healthcare insurance
4
Assis foster care transition
1
Program Outcomes
Completed Workforce Readiness/Life Skills training
12
Placed in internship
10
Completed Internship
9
Obtained employment post- internship
9
Youth engaged in positive male development program
120
APPENDIX C. CHANGING HEARTS REPORT
In accordance with the CHNA performed in 2012 and the implementation strategy of LifeBridge Health entities, the
LifeBridge Health Office of Community Health Improvement (OCHI) created the Changing Hearts Community Health
Improvement Program. The Changing Hearts Program (CHP) is designed to improve the cardiovascular health of individuals in the community. CHP helps individuals understand their identified risk for heart disease, how to minimize
and/or modify those risk factors and how to maintain a healthy lifestyle to prevent heart disease.
As noted in previous sections of this report, community members surveyed selected heart disease as the leading cause
of death. In addition, several other health concerns were mentioned, such as diabetes and stroke. Based on clinical
evidence, data collected and forum responses; OCHI considered other clinical conditions mentioned previously as the
heart disease ‘cluster’ as the program was formulated. These conditions, similar to metabolic syndrome, are often
mentioned as precursors to heart disease and include but are not limited to high blood pressure, high cholesterol, obesity, and diabetes. CHP is a free program designed to address the needs of those in the community who are at high risk
for and/or currently living with one or more of these heart disease-related conditions. The Changing Hearts Program
includes the following elements:







Live Heart Health Risk Assessment (Blood pressure reading, body composition analysis, cholesterol, glucose and other essential blood work)
Health education and counseling with a registered nurse
Materials to facilitate lifestyle change
Follow-up phone calls and/or home visits with a community health worker focusing on individualized
plan developed with participants (some receive home visits from registered nurse)
Workshops to maintain lifestyle change
Links to resources to improve cardiac health (exercise classes, nutrition programs, etc.)
Links to resources to gain and improve access to appropriate health care services
Changing Hearts addresses many aspects of care, prevention, and wellness by first determining risk, then assessing
clinical needs, social needs and healthcare access. Overall operations of CHP implementation combined the fact that
one must assess current clinical status and risk of participants, yet also include other elements. Evidence-based practice and the success of previous programs offered by LifeBridge Health demonstrate that outcomes are better when
combining clinical interventions with those that assist participants with social determinants. Social determinants have
an overall effect on health status, and the addition of a community health worker enabled CHP to help participants
with wellness strategies related not only to their clinical status, but also related to their social needs.
CHP targets people in the community, who are medically under-served, range in age from eighteen to seventy, live
within established residential boundaries as determined by hospital services areas and meet clinical criteria. Participants are monitored based on and individualized and mutually agreed upon plan of care. They receive information on
and assistance in obtaining access to care, maintaining healthy lifestyles, and clinical aspects of health maintenance.
Program Goals
The goals of the Changing Hearts Program are as follows:
 75% of CHP participants will demonstrate the adaptation of lifestyle changes that minimize and/or decrease risk of heart disease
 75% of participants presenting to the program will demonstrate an increased rate of accessing health care
and other resources as evidenced by attendance at organized appointments during the duration of program activities
APPENDIX C. CHANGING HEARTS REPORT


75% of participants enrolled in CHP will demonstrate a decrease in the level of risk identified according to
clinical criteria measured during the program
75% of participants enrolled in the CHP will demonstrate an improved quality of life as measured by a
standardized instrument adopted from the University of Minnesota11
The clinical criteria measured for the program include blood pressure, blood glucose level, cholesterol levels, and
body mass index. The program begins with the live risk assessment, followed by an initial home visit for more indepth assessment, medication reconciliation as needed, and individual counseling with participants and family members if necessary or requested. Workshops held monthly related to lifestyle change and maintenance monthly various locations; often serve as support groups for those involved in the program.
The LifeBridge Health Office of Community Health Improvement consists of one part-time Registered Nurse Health
Educator, one Registered Nurse (also department manager), and one full-time Community Health Worker
(Community Health Improvement Associate). In July 2013 planning began for the CHP, and by September 2013 the
program started with our first partner and recruitment with Baltimore Head Start who was having a meeting at the
Zeta Center for Healthy and Active Aging in Baltimore City (21215). The standard method of recruitment is to work
with various partner organizations to provide information about the program and be available on-site for enrollment.
From September 2013 through December 2015 there were 128 recruitment events held in the community. During
those events, 1,947 people were recruited for the program, of which 435 completed eligibility surveys. In many instances upon calling to schedule an appointment for a risk assessment to begin the program, people were no longer
interested, were medically ineligible due to having conditions including but not limited to end stage cancer, end stage
renal disease, morbid obesity, or an existing heart condition. There were cases where people determined that the
year-long commitment was too long, or they did not want to attend workshops. The program begins with the live risk
assessment, followed by an initial home visit for more in-depth assessment, medication reconciliation as needed, and
individual counseling with participants and family members if necessary or requested. In the event that a potential
participant did not want to receive home visits, CHP staff made arrangements to meet in a different place that provided adequate privacy and some accepted the compromise.
Changing Hearts provides in-person risk assessments, during which time participants receive biometric information
from CHP RN’s and some received on-the-spot counseling. The clinical criteria measured for the program include
blood pressure, blood glucose level, cholesterol levels, and body mass index. The assessments are also a time to engage with CHP’s CHW, who makes referrals for psychosocial needs that include but are not limited to transportation,
enrollment in health insurance programs, mediation assistance, and other things related to the social determinants
that affect health status. The links provided by the CHW enable participants to access health care on a consistent
basis and follow- up when necessary.
A component of the program is the workshops held monthly in various locations, to cover subjects that will teach and
empower participants to make lifestyle changes and continue living well upon program completion. Workshop topics
covered include, but are not limited to:
 Understanding Your Lab Results
 Healthy Eating and Heart Health
 Physical Activity and Heart Health
 Managing Medications
 Talking to Your Healthcare Provider
 Stress Management and Relaxation
 Heart Attack and Stroke Signs and Symptoms,
 Metabolic Syndrome
 Smoking Cessation (if needed or requested for participant and/or family members)
 Tying It All Together for a Healthier You (How all subjects connect to create a healthier heart)
APPENDIX C. CHANGING HEARTS REPORT
Workshops serve as a support group for participants as they began to share experiences, ideas for facilitating change,
barriers to change, and other subjects. Topics cover general ideas that will aid in wellness for any illness; specifics were
addressed based on the group dynamic and/or during individual home visits. In the event that the CHW was performing the home visit and more counseling was needed; RN’s then visited the client as follow up. Over 139 workshops
were held with 203 attendees.
The following report card outlines the program outcomes since program inception.
Changing Hearts Preliminary Report Card– LifeBridge
(September 2013- December 2015)
Number of recruitment events*
Number of people approached for recruitment*
Number of people eligible for program*
Number of clients with completed Health Risk Assessment*
128
1947
435
181
Number of clients graduated with initial and final program assessments completed
65
*Recorded information applies for Sinai participants only.
Biometric Outcomes
n= 65 LBH participants
% Change
Direction
of Change
Systolic blood pressure
100%
↓
Diastolic blood pressure
100%
↓
Glucose measurement
35%
↓
LDL measurement
35%
↓
HDL measurement
52%
↓
*Note: cumulative changes in category transitions applied
Behavioral Outcomes
n= 65 LBH participants
% Change
Direction
of Change
Smoking Habits
2%
↑
Physical Activity
33%
↑
Nutritional Concerns
15%
↓
Quality of Life Score
2%
↑
Access to primary care provider and services
26%
↑
APPENDIX D. SAFE PROJECT REPORT
The five types of elder abuse are physical, sexual, psychological, financial, and neglect. Less than one in fourteen cases
of elder abuse is reported to law enforcement. Stop Abuse of Elders (SAFE), shows that the Jewish community cares
about elders. In collaboration with Jewish Community Services and Levindale Hebrew Geriatric Center and Hospital,
CHANA seeks to prevent the incidence and lessen the consequences of elder abuse. SAFE also offers supportive services for individuals, families and concerned members of the community. We work with elders, family members and
friends of older adults who are concerned about their safety and well-being. This collaboration assures the community
of an effective and coordinated response for victims, perpetrators, and their families and provides prevention education for the entire community. To provide a comprehensive approach SAFE includes: crisis intervention, shelter, psychotherapy, advocacy, service coordination and community education. Outcomes will be based on the ability to increase awareness in the community of elder abuse and how to access services as well as the number of clients who
receive services including crisis management, services coordination and shelter.
Looking Forward
As the partnership progresses future goals include increasing the skills of traditional domestic violence advocates in
interventions appropriate for older adult victims, provide a point person for all elder abuse related issues in Northwest
Baltimore, and develop policies and procedures to support staff aiding victims and survivors.
The following report card outline preliminary outcomes of the SAFE Project.
SAFE Project Outcomes
Goal
Actual
Awareness : Reaching people with information on Elder Abuse
Seniors
500
235
Clergy Members
20
80
1000
8000
Community Members
Education: Train service providers and other professionals to incorporate elder abuse
knowledge into their work
Collaborate with public agencies
150
150
Educate attorneys
40
75
Educate professionals
30
150
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1
Baltimore Neighborhoods Profiles (2013). http://health.baltimorecity.gov/sites/default/files/Health%20Disparities%20Report%
20Card%20FINAL%2024-Apr-14.pdf
2
Community QuickFacts (2015) https://www.census.gov/quickfacts/table/PST045215/00
3
Baltimore City Neighborhood Health Profiles (2011). http://health.baltimorecity.gov/sites/default/files/45%20Pimlico.pdf
4
Baltimore City Health Disparities Report Card (2013). http://health.baltimorecity.gov/sites/default/files/Health%20Disparities%
20Report%20Card%20FINAL%2024-Apr-14.pdf
5
Baltimore County Community Health Needs Assessment (2015). http://resources.baltimorecountymd.gov/Documents/Health/
communityhealthassessment.pdf
6
Maryland Vital Statistics Annual Report (2013). http://dhmh.maryland.gov/vsa/documents/13annual.pdf
7
Community Need Index. (2016) http://cni.chw-interactive.org
8
American Heart Association. (2016) http://my.americanheart.org/professional/index.jsp
9
Healthy Baltimore 2014. http://health.baltimorecity.gov/healthy-baltimore-2015
10
2010 National Elder Mistreatment Study. (2010) https://www.ncjrs.gov/pdffiles1/nij/grants/226456.pdf
11
American Heart Association. (2016) http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/CoronaryArtery-Disease---Coronary-Heart-Disease_UCM_436416_Article.jsp?gc
12
Substance Use Disorders and the Person-Centered Healthcare Home. (2010) http://www.integration.samhsa.gov/integrated-care
-models/National_Council_SU_Report.pdf
13
Maryland Network Against Domestic Violence Annual Report. (2015) http://mnadv.org/_mnadvWeb/wp-content/
uploads/2011/07/Annual-Report-2015.pdf
14
U.S. Department of Health and Human Services Health Resources and Services Administration. (2016) http://www.hrsa.gov/
shortage/mua/
LifeBridge Health 2014 Community Benefit Report. http://edition.pagesuite-professional.co.uk/Launch.aspx?EID=a5db587a-7d6a4c36-8e2e-7b8592ec1be0