Acknowledgements
Authors and originators:
Rickie Brawer, PhD, MPH, MCHES, Associate Director, Center for Urban Health, Thomas Jefferson
University Hospital and Assistant Professor, Department of Family and Community Medicine,
Jefferson University, Sidney Kimmel Medical College
Marianna Calabrese, MA, Manager, Community Benefit
Kathryn McCarter, RN, MSHA, CCP, Director of Community Health
Consultants:
Jane Elkis Berkowitz, MRP, MA
Karen Arnone, Financial and Market Planning
Community Benefit Acknowledgement:
Thank you to the key community stakeholders in the Abington and Lansdale communities who
participated in the conversations, Community Health Need Assessment interviews, focus groups, and
follow up meetings.
Thank you to the Abington Jefferson Health administration, physicians, leaders, and employees who
participated in interviews, focus groups, and follow up meetings.
We would like to acknowledge the time and continued support of the Abington Health Foundation
Community Benefit Committee for their time, expertise, leadership, and support during the process.
ii
Table of Contents
Executive Summary
ii
Introduction
1
Purpose of the Community Health Needs Assessment
5
Community Health Needs Assessment Methods
7
Community Health Needs Assessment Findings
13
Bucks/Montgomery Counties and Abington Community Benefit Area Demographics
14
Social Determinants of Health
18
Health Care Access
39
Health Status
Mortality
49
Maternal and Child Health
54
Morbidity
58
Preventive Care and Early Detection of Disease
75
Health Behaviors
84
Special Populations
Older Adults
99
Immigrants and Refugees
132
Homeless
137
Recommendations
139
Appendices
142
References
170
i
Executive Summary
Abington - Jefferson Health (AJH) is a Pennsylvania nonprofit organization located in Montgomery
County, Pennsylvania that considers its community benefit service area to include proximate portions
of Montgomery and Bucks counties where almost 544,000 people live. This Community Health
Needs Assessment (CHNA) utilizes information collected from the Public Health Management
Corporation's household health survey, numerous secondary data and literature sources, and internal
experts and external representatives of health care and community based organizations who have
knowledge of the health and social conditions of these communities.
AJH's community benefit area is an area with relatively low underlying economic and structural
barriers such as income, culture/language, education, insurance, and housing, that affect overall
health. Most health status indicators are improving, and many are better than the Healthy People
2020 goal (note that there is not a Healthy People 2020 target for many of the health status measures
described in this CHNA). Racial/ethnic and income disparities exist, and for most indicators, people
of color and/or Hispanic origin fare worse than their white neighbors.
In addition to extensive information about the population residing in the community benefit areas,
this CHNA includes focused sections on the following special populations: adults age 60+,
immigrants/refugees, and the homeless.
While the majority of health status measures indicate minimal to moderate deficiencies or hardship,
there is a portion of the population in serious need of support for a variety of issues. The following
are health status measures related to the overall population that do not meet the Healthy People 2020
goal in Bucks/Montgomery Counties and/or the Abington CB service areas:
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Insured adults and children
Regular source of care (children, adults, age 60+)
First trimester prenatal care
Hypertension (adults, age 60+)
Obesity (children)
HIV testing (adults, age 60+)
PAP testing (adults, age 60+)
Mammography (adults, age 60+)
Smokers (adults)
Smokers who tried to quit (adults, age 60+)
Female breast cancer mortality
Stroke mortality
Although some of measures exceed the Healthy People 2020 goal, according to the Centers for
Disease Control Community Health Status Indicators methodology, the following are in the least
favorable quartile when compared to peer counties:
Bucks
Overall cancer deaths
Motor vehicle deaths
ii
Montgomery
X
X
Bucks
Stroke deaths
Unintentional injury (including motor vehicle) deaths
Older adult depression
Alzheimers/Dementia
Adult smoking
Cancer morbidity
Syphilis
Gonorrhea
Older adult preventable hospitalizations
Adult female routine PAP tests
Inadequate social support
Unemployment
X
X
Montgomery
X
X
X
X
X
X
X
X
X
X
X
X
In addition, the Pennsylvania Department of Health 2015-2020 State Health Improvement Plan's top
5 priorities for Southeastern Pennsylvania are:
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integration of healthcare and behavioral/mental healthcare
preventive screenings
obesity
behavioral/mental health for adults
primary care
Using the quantitative and qualitative data presented in this CHNA and a prioritization process, AJH
identified the following most important priority health needs for the population of the Abington CB
areas:
Mental Health Services
Obesity
Social and Health Care Needs of Older Adults
Alcohol/ Substance Abuse
Women's Cancer
Chronic Disease Management (diabetes, heart disease and hypertension, stroke, asthma)
Colon Cancer
Health Education, Social Services and Regular Source of Care
The Community Health Department of Abington Jefferson Health, working under the guidance of the
Abington Health Foundation Community Benefit Committee is responsible for developing
implementation plans focusing on priority issues including the above listed most important health
needs.
iii
Introduction
Over the past century the major causes of morbidity and mortality in the United States have shifted
from those related to communicable diseases to those due to chronic diseases. Just as the major
causes of morbidity and mortality have changed, so too has understanding of health and what makes
people healthy or ill. Research has documented the importance of the social determinants of health
(for example, socioeconomic status and education), which affect health directly as well as through
their impact on other health determinants such as risk factors. Targeting interventions toward the
conditions associated with today’s challenges to living a healthy life requires an increased emphasis
on the factors that affect the current causes of morbidity and mortality, factors such as the social
determinants of health. Many community-based prevention interventions target such conditions.
Community-based prevention interventions offer three distinct strengths. First, because the
intervention is implemented population-wide it is inclusive and not dependent on access to the health
care system. Second, by directing strategies at an entire population an intervention can reach
individuals at all levels of risk. And finally, some lifestyle and behavioral risk factors are shaped by
conditions not under an individual’s control. For example, encouraging an individual to eat healthy
food when none is accessible undermines the potential for successful behavioral change. Communitybased prevention interventions can be designed to affect environmental and social conditions that are
out of the reach of clinical services.1
Description of Abington Jefferson Health
Effective April 30, 2015 at 11:59 pm, Thomas Jefferson University (TJU), a Pennsylvania nonprofit
organization that is exempt from federal income taxation pursuant to Section 501(c)(3) of the Internal
Revenue Code, became the sole corporate member of Abington Health (AH). As a result of this
transaction, AH and its subsidiaries, Abington Memorial Hospital, Lansdale Hospital, and Abington
Health Foundation (collectively, the "Subsidiaries"), became subsidiaries of TJU, creating a
university health system, known as Jefferson, that encompasses Thomas Jefferson University plus
Jefferson Health, the new combined clinical brand for the five hospitals and physician networks
within the system.
The newly named Abington – Jefferson Health (AJH) is the organization that encompasses its
flagship hospital, Abington Hospital in Abington, PA (the largest community teaching hospital in
Montgomery or Bucks counties) and Abington – Lansdale Hospital in Hatfield Township, PA, as well
as a number of outpatient settings for obtaining expert medical care in Bucks, Montgomery, and
Philadelphia counties.
Abington – Jefferson Health entities include the following:
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Two hospitals: Together, Abington Hospital and Abington – Lansdale Hospital have 800
licensed beds
Five outpatient campuses: Abington Health Center – Blue Bell, Abington Health Center –
Lower Gwynedd, Abington Health Center – Montgomeryville, Abington Health Center –
Warminster and Abington Health Center – Willow Grove
Two urgent care centers, one in Feasterville and one in Flourtown
1
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Abington Health Physicians – Physician practices located in Bucks, Montgomery, and
Philadelphia counties with 65 locations
Abington Hospital, founded in 1914, is the largest community teaching hospital in Montgomery or
Bucks counties. Staff members have the privilege of working with medical students, residents and
fellows from various medical schools and training programs in the Philadelphia area. The hospital
sponsors five residency programs: family medicine, internal medicine, obstetrics/gynecology, general
surgery and dentistry. In addition, the hospital provides postgraduate medical education in affiliation
with several area medical schools. Abington also operates the Dixon School of Nursing and supports
a pharmacy residency program.
Each year, AJH treats 125,000 patients in its two Emergency Departments with Abington Hospital
having the distinction as the only Level II trauma center in Montgomery County. Abington Hospital –
Jefferson Health has a comprehensive stroke center and offers highly advanced programs in cancer,
cardiac, and orthopaedic care.
AJH employs approximately 6,000 employees who work with 1,400 physicians and serve more than
34,000 inpatients and almost 665,000 outpatient visits annually.
As noted in its Strategic Plan, the mission of the Community Health Department at AJH is to develop
targeted health outreach programs and screenings in response to the identified needs of its community
in concert with the mission of Jefferson Health: Health is all we do. The vision aims to create the
healthiest community by orchestrating targeted outreach for maximum community benefit while
reducing health disparities.
Models
With the growing burden of chronic disease, the medical and public health communities including
AJH are reexamining their roles and opportunities for more effective prevention and clinical
interventions. The potential to significantly improve chronic disease prevention and impact morbidity
and mortality from chronic conditions is enhanced by adopting strategies that incorporate a social
ecology perspective, realigning the patient-physician relationship, integrating population health
perspectives into the chronic care model, and effectively engaging communities.
Abington highly values the principles of community engagement articulated by the Centers for
Disease Control and has built its community benefit efforts on a community engagement model.
Principles of Community Engagement2
Principle
Set Goals
Key elements
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Clarify the purposes/goals of the engagement effort
Specify populations and/or communities
2
Principle
Study community
Build trust
Encourage selfdetermination
Key elements
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Establish partnerships
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Respect diversity
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Identify community assets
and develop capacity
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Economic conditions
Political structures
Norms and values
Demographic trends
History
Experience with engagement efforts
Perceptions of those initiating the engagement activities
Establish relationships
Work with the formal and informal leadership
Seek commitment from community organizations and
leaders
Create processes for mobilizing the community
Community self-determination is the responsibility and right
of all people
No external entity should assume that it can bestow on a
community the power to act in its own self-interest
Equitable partnerships are necessary for success
Utilize multiple engagement strategies
Explicitly recognize cultural influences
View community structures as resources for change and
action
Provide experts and resources to assist with analysis,
decision-making, and action
Provide support to develop leadership training, meeting
facilitation, skill building
Release control to the
community

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Include as many elements of a community as possible
Adapt to meet changing needs and growth
Make a long-term
commitment

Recognize different stages of development and provide
ongoing technical assistance
AJH also recognizes the value of an Expanded Chronic Care Model3 as a framework for addressing
chronic disease in a comprehensive way that respects clinical care, the health system, community, and
patients as equal partners in meeting the triple aim of improving population health, the patient
experience, and reducing per capita costs.
3
Community
Build Healthy
Policy
Health System
Create
Supportive
Environment
Strengthen
Community
Action
Activated
Community
Activated
Patient
SelfManagement
Information
Delivery
System
Redesig
n
Productive Interactions
and Continuous
Relationships
Decision
Support
pport
Activated
Team
Proactive
Community
AJH Community Health leaders with support of the Community Benefit Committee recommends
using the following model4 to guide planning and programmatic efforts, and to explain to internal and
external stakeholders the rationale for the Community Health implementation plan.
4
Purpose of the Community Health Needs Assessment (CHNA)
Ongoing, unprecedented increases in the demand for healthcare are challenging for communities and
healthcare providers in this era of limited fiscal resources. Regulatory changes also have resulted in
new obligations. One of the mandates of the Health Care Reform Act is a Community Health Needs
Assessment. Starting in 2013, every three years tax-exempt hospitals must conduct an assessment and
implement strategies to address priority needs. The Health Reform Act spells out requirements for the
Community Health Needs Assessment. This assessment is central to an organization’s community
benefit/social accountability plan. By determining and examining the service needs and gaps in a
community, an organization can develop responses to address them.
A Community Health Needs Assessment is a disciplined approach to collecting, analyzing, and using
data, including community input, to identify barriers to the health and well-being of its residents and
communities, leading to the development of goals and targeted action plans to achieve those goals.
The assessment findings can be linked to clinical decision making within health care systems as well
as connected to community health improvement efforts. The assessment engages health care
providers and the broader community by providing a basis for making informed decisions, with a
strong emphasis on preventing illness and reducing health disparities.
Specifically, the Patient Protection and Affordable Care Act (PPACA) mandates a new section in the
IRS Code –Section 501(r) for hospitals to obtain/maintain 501(c)(3) status:
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Each hospital facility must conduct a community health needs assessment at least once every
three taxable years and adopt an implementation strategy to meet the community health needs
identified through the assessment
The community health needs assessment must take into account input from persons who
represent the broad interests of the community served by the hospital facility, including those
with special knowledge of or public health expertise
The CHNA must be made widely available to the public
For the 2016 CHNA, the Department of Treasury and the IRS is encouraging cross institution
collaboration. To that end the Healthcare Improvement Foundation, in partnership with the Hospital
and Health System Association of Pennsylvania and the U.S. Department of Health and Human
Services (Region 3) has convened the region’s hospitals in the Collaborative Opportunities to
Advance Community Health (COACH) Project. The goals of COACH are to:

 Gather input from public health authorities and key community stakeholders
 Explore growing number of health and epidemiologic data sources
 Collaborate with public health and other stakeholders to prioritize needs, coordinate
interventions, and establish measures for evaluating results
Additionally, the Health Care Improvement Foundation is facilitating a Montgomery County Hospital
Partnership. The partnership's role will be similar to COACH with an exclusive focus on
Montgomery County, and all hospitals, whether profit or non-profit, will be involved.
5
Four principles are guiding the development of a strategy for leveraging community benefit programs
to increase their influence: defining mutually agreed-on regional geographic boundaries to align both
community benefit and accountable health community initiatives, ensuring that community benefit
activities use evidence to prioritize interventions, increasing the scale and effectiveness of community
benefit investments by pooling some resources, and establishing shared measurement and
accountability for regional population health improvement.5
Overall Roles and Responsibilities
To undertake this mandate, Abington Health Foundation formed a Community Benefit Committee.
The committee is responsible for overseeing and recommending policies and programs designed to
carry out the charitable mission of Abington Hospital and Abington-Lansdale Hospital, protect its
non-profit status, and to enhance the health status of communities served by Abington Jefferson
Health based on the results of a community health needs assessment.
Specifically, the Committee was charged to:
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Oversee the conduct of a community health needs assessment at least every three (3) years.
Review, and recommend for approval a Community Benefit Plan outlining long-term strategies
based on a community health needs assessment and other objective sources of data, and
recommend updates to such Plan.
Guide and monitor the planning, development, and implementation of programs aimed at
improving the health status of the local community consistent with the Community Benefit Plan.
Establish criteria for priority-setting among potential community benefit activities and projects,
consistent with financial capabilities and resource limitations.
Periodically make recommendations for program continuation or termination based on progress
toward identified measurable objectives, available resources, level of community ownership, and
alignment with criteria for priorities.
Review and make recommendations regarding the annual Community Benefit Report, including
the information provided to the IRS on Form 990. Additionally, identify opportunities for
disseminating information to the public about the organization’s community benefit activities.
Review annual goals specifying principal work focus areas for the coming year. Review hospital
financial assistance policies and practices and provide recommendations as necessary in an effort
to increase efforts to communicate these policies.
The Community Benefit Committee are trustees, staff, physicians, dentists, nurses and other
clinicians. The Committee may also invite, as guests, various representatives of the communities
served by Abington Jefferson Health.
Abington's Community Benefit areas are defined as the areas proximate to the hospital where
approximately 70% of inpatients reside. This includes communities in Montgomery and Bucks
counties that are aggregated into 7 geographically contiguous regions defined by zip codes. When
analyzing PHMC survey data for older adults and children, the regions are further consolidated into 3
areas to ensure that the sample size is adequate for statistically reliable results. For comparisons, the
combined data for Bucks and Montgomery counties is provided.
6
Abington’s Community Benefit Program (CBP) adopts a comprehensive notion of health
determinants that are spread across domains of behavioral risk, social and economic circumstances,
and medical care. The balance and effects of many of these determinants, e.g. availability of healthy
foods, parks and other safe places to play and exercise, and safe housing, are specific to Abington’s
locale and are built into the Community Benefit Plan.
Community Health Needs Assessment Methods
Literature Review and Secondary Data Sources
In preparation for the community health needs assessment more than 20 secondary data sources were
reviewed including:
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2015 The Nielsen Company, © 2015 Truven Health Analytics Inc
American Community Survey
American Diabetes Association
Behavior Risk Factor Surveillance System (BRFSS)
Bucks County Area Agency on Aging
Centers for Disease Control and Prevention
Community Commons
Community Needs Index
County Health Rankings and Roadmaps 2015
Enroll America
Feeding America – Map the Meal Gap
Healthy People 2020
Kaiser Family – State Health Facts
Montgomery County Comprehensive Plan: Montco 2040: A Shared Vision
Montgomery County Health Department
Montgomery Office of Aging and Adult Services
Pennsylvania Department of Health
Public Health Management Corporation - Household Health Survey
US Census Bureau
Various articles from academic journals
Various articles from the popular press
Youth Risk Behavior Surveillance System (YRBSS) 2013
Primary Data Sources:
Interviews
Almost 30 interviews were conducted with individuals representing health care and community based
organizations who have knowledge of the health and underlying social conditions that affect health of
people in their neighborhood and broader community. These interviews were conducted by Abington
Jefferson Health Community Benefit leaders to gain insight about health needs and priorities, barriers
to improving community health, and the community assets and efforts already in place or being
planned to address these issues and concerns. In addition, interviews were conducted with faculty and
health providers from Abington Jefferson Health to gain their perspective about the health issues of
7
their patients and community and to identify Abington's and others' efforts to address these issues.
Interviewees were asked to prioritize the needs/recommendations discussed during their interview.
The table below lists the affiliation of interviewees, their positions, and the focus of the interview
based on their area(s) of expertise.
Organization
Abington and Abington Lansdale Hospitals
Position
Financial Counseling
Center - Director/Mgr
Focus
Access to Care, Older Adults
Abington Community
Taskforce
Chairs of ACT (2)
Access to Care, Mental Health/Behavioral
Health, Healthy Lifestyles, Access to
Care, Homeless, Nutrition/Food
Insecurity
Abington Diversity and
Director, Student Intern
Inclusion and Diversity Student
Co-Op
Workforce/Cultural Competence,
Communication, Access to Care, Mental
Health, Social Determinants
Abington Family Medicine
Physicians/faculty, Leaders
and Staff
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Director of Nutrition
Services and Clinical
Nutrition Manager
Food Insecurity and Nutrition, Social
Determinants, Older Adults, Chronic
Care
Abington Hospital
Director of Service
Excellence
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Director of Rehab Medicine
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Manager of ASU and Care
Mgr
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Corporate Director of
PR/Marketing
Access, Social Determinants,
Communication
Abington Hospital
Director of Clinical
Integration
Drug/Alcohol, Access, Social
Determinants
Abington Hospital
Manager of Diabetes Center
Diabetes, Chronic Care
Abington Hospital
Director of Case
Management/SW and
Manager
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Geriatric Service Line
Older adults, Chronic Care, Access,
Social Determinants, Communication,
Substance Abuse, Obesity/Food
Insecurity/Nutrition
8
Organization
Abington Hospital
Position
Cardiac Service Line
Focus
Heart disease, Communication, Social
Determinants, Chronic Care
Abington Hospital
Neuro Service Line
Neurological Disease, Mental
Health/Behavioral Health, Older Adults
Abington Hospital
Care Managers AHP
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital
Post Acute
Leadership/Home Care
Access to Care, Workplace, Chronic Care
Abington Hospital
Director ETC; SANE
examiners/Encare
Mental Health, Communication, Access
to Care, Safety and Violence, Drug and
Alcohol
Abington Hospital
Chaplain, Pastoral Care,
Domestic Violence Social
Worker
Mental Health, Communication,
Domestic Violence, Older Adults, Access
to care, Substance Abuse, Nutrition and
Food Insecurity
Abington Hospital AFM
Nurse
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington Hospital Behavioral
Health
Director
Mental Health/Behavioral Health
Abington Hospital Rosenfeld
Cancer Center
Staff
Cancer, Chronic Care
Abington Jefferson Health
Abington medical staff
Corporate HR Director
Hospitalists
Workforce
Inpatients, Access to Care, Chronic Care,
Social Determinants
Abington medical staff
VP Physician Services
Abington Police Department
and Abington HUB
Lieutenant Commander,
Director of Youth
Programs, Officer
Safety and Violence Prevention, Social
Determinants of Health, Access
Workplace, Homeless, Cultural, Chronic
Care
Safety and Violence Prevention,
Communication, Cultural, Access to
Care, Social Determinants of Health,
Mental Health/Behavioral Health
Abington population health
physician
Director of Population
Health
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Abington School District
Community
Relations/Admin and
Director of Pupil Services
Children, Access to Care and Behavioral
Health Needs, Social Determinants of
Health, Chronic Care [Allergy, Asthma,
Vision]
9
Organization
Abington Women and
Children’s Service Line
Position
Leadership, Physician, and
Staff
Focus
Women and children; Safety and
Violence Prevention, Social Determinants
of Health, Workplace, Homeless,
Cultural, Chronic Care
Aldersgate
Executive Director and staff
Children, Drug and Alcohol Programs,
Access to Care, Social Determinants
Crestmont Community Focus
Group
Community Leaders
Access to Care, Mental Health/Behavioral
Health, Programs
Emergency Services,
Warminster area
Director
Emergency Response, Drugs, Chronic
Disease [Stroke/Heart], Access to Care,
Social Determinants
Indian Valley YMCA
Branch Director
Nutrition and Food Insecurity, Access to
Care
Jaisohn Center
Current and Retired
President (s)
Koreans, Cultural, Access to Care,
Chronic Care, Language
Jenkintown Council
All Panel
Food Insecurity, Nutrition, Social
Determinants of Health
LaMott Community Center,
Cheltenham
Director
Older adults, Access to Care, Social
Determinants
Lansdale Clinics
Staff
Access to Care, Mental health/Behavioral
Health, Nutrition/Food Insecurity
Abington - Lansdale Hospital
Senior Leaders
Abington - Lansdale Hospital
HR/Workforce
Development
Food insecurity/Nutrition, Access to
Care, Mental Health/Behavioral Health,
Chronic Care
Workforce, Access to Care, Social
Determinants
Abington - Lansdale Hospital
Hospitalist
Inpatients, Access to Care, Chronic Care,
Social Determinants, Mental Health
Abington - Lansdale Hospital
Emergency Room Team
Coordinator
Mental Health
Latino Ministries, Casa Del
Pueblo, Lehman United
Methodist Church, Hatboro
Manna on Main Street
Pastor/Outreach Worker
Latinos, Access to Care [Dental], Vision,
Cultural
Executive Director
Food Insecurity, Access for Underserved,
Mental Health, Homeless
Montgomery County Aging
and Adult Services
Acting Director
Older Adults
10
Organization
Montgomery County Health
Department
Position
Director of Health/Medical
Director; Deputy Director
of Personal Health
Services; Division Director
of Clinical Services and
Public Health Nursing;
Epidemiologist; Division
Director of Health
Promotion
Health & Wellness
Supervisor
Focus
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
North Penn Community Health
Foundation
President and CEO
Chronic Care, Mental Health, Access to
Care [Dental], Care Coordination
North Penn Mosque
Leader
North Penn School District
District Nurse Coordinator
North Penn United Way
Director
North Penn YMCA
Branch Director
Muslims, Access to Care, Poverty, Social
Determinants
Children, Poverty, Social Determinants,
Mental Health
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Nutrition and Food Insecurity, Access to
Care
Philadelphia Freedom Valley
YMCA - Abington
Program Director
Access to Care, Nutrition and Food
Insecurity
Philadelphia Freedom Valley
YMCA - Ambler
Nutrition and Food Insecurity, Access to
Care
Souderton Area School District
Group Vice
President/Executive
Director
District Nurse Coordinator
Target Pharmacy, Abington
Pharmacist
Visiting Nurse AssociationCommunity Services, Abington
VNA Foundation of North
Penn
Willow Grove United
Methodist Church
Executive Director; Social
Services Program Manager
Executive Director
Montgomery County
Intermediate Unit
Wissahickon School District
Volunteer and West Chester
University Nursing
Professor
Nurse Coordinator
11
Mental health, Nutrition/Food Insecurity,
Access to Care
Children, Mental Health/Substance
Abuse, Nutrition/Food Insecurity, Access
to Care
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Access to Care, Older Adults, Homeless
Older Adults, Access to Care
Safety and Violence Prevention, Social
Determinants of Health, Workplace,
Homeless, Cultural, Chronic Care
Children, Social Determinants of Health,
Mental Health/Substance Abuse, Access
to Care, Nutrition/Food Insecurity
Focus/Small Group Interviews
A focus group was conducted with community leaders who live in Crestmont, a Willow Grove
neighborhood within Abington's CB area. This area was selected to raise awareness among the
community about the health needs assessment and to engage leaders in future efforts to improve
community health. Focus group questions were designed to elicit the major health and social concerns
of the neighborhood and larger community, barriers to accessing health and social services and
improving lifestyles, perceptions about existing and/or potential interventions to address community
health improvement, and what specifically Abington - Jefferson Health could do to improve the
health of the community.
In addition, several small group interviews were held with representatives of:
Montgomery County Health Department
AJH Care Managers
Pastoral Care/Domestic Violence Social Work
Muller Institute for Senior Health
The smaller group setting allowed for a concentrated focus and exploration of community needs.
Additionally, recommendations from the Pennsylvania Department of Health 2015-2020 State Health
Improvement Plan stakeholder meetings were considered. In March 2015, 177 attendees participated
in six stakeholder meetings as part of a collaborative effort to identify key health issues. The top 5
priorities identified for Southeastern Pennsylvania are:





integration of healthcare and behavioral/mental healthcare
preventive screenings
obesity
behavioral/mental health for adults
primary care
12
Community Health Needs Assessment Findings
The results from the Community Health Needs Assessment are organized into the following
categories:
 Demographics
 Social Determinants of Health
o Education
o Income and poverty
o Access to healthy and affordable food
o Employment and job training
o Community safety
o Family and social support
o Built and natural environment
o Healthcare access
 Health insurance
 Source of care
 Transportation
 Literacy
 Cultural competence and language
 Health Status
o Mortality
o Maternal and child health
o Morbidity
o Preventive care and early detection of disease
o Health behaviors
 Special Populations
o Older Adults
o Immigrants and Refugees
o Homeless
13
Bucks and Montgomery Counties and Abington Community Benefit Area
Demographics
More than 1.4 million people live in Bucks (627,000) and Montgomery counties (812,000).
According to the County Health Rankings and Roadmaps 2015, the population of Bucks County is
86% non-Hispanic white, 4% non-Hispanic African America,a 5% Hispanic or Latinob, and 4%
Asian. Montgomery County's racial/ethnic distribution is 78% non-Hispanic white, 9% non-Hispanic
African American, 5% Hispanic or Latino, and 7% Asian. The demographic profiles of these
counties is fairly similar to the profile of the Commonwealth of Pennsylvania with 78% non-Hispanic
white, 10% non-Hispanic African American, 6% Hispanic or Latino, and 3% Asian.
The proportion of residents aged less than 18 in Pennsylvania, Bucks, and Montgomery counties is
21-22%, and the proportion age 65+ is 16% in all three regions.
Median household income in Bucks ($73,662) and Montgomery ($77,021) counties is significantly
higher than for Pennsylvania ($52,005). Approximately 2% are not proficient in English in each of
the 3 geographies.
Abington Jefferson Health has geographically defined its community benefit (CB) area in the
following way:
Region
Zip Codes
North Penn
18915, 18936, 19440, 19446, 19454
Indian Valley
18964, 18969, 19438
William Tennent
18966, 18974
Central Bucks
18914, 18929, 18932, 18976
Lower Eastern
19012, 19027, 19038, 19046, 19095
Abington
19001, 19006, 19009, 19040, 19090
Upper Dublin
19002, 19025, 19031, 19034, 19044, 19075, 19422, 19436, 19437, 19477
a
The terms black or African American are both used in this document depending on the source of the data. According to
the Census Bureau website, these terms are used interchangeably and refer to people having origins in any of the black
racial groups of Africa. (https://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf)
b
The terms Latino and Hispanic are both used in this document depending on the source of the data. According to the
U.S. Census Bureau "Hispanics or Latinos are those people who classified themselves in one of the specific Spanish,
Hispanic, or Latino categories ... -"Mexican," "Puerto Rican", or "Cuban"-as well as those who indicate that they are
"another Hispanic, Latino, or Spanish origin." .... The terms "Hispanic," "Latino," and "Spanish" are used
interchangeably."
14
These zip codes define regions that are in Bucks and Montgomery counties. For comparative
purposes throughout this document, the combined area of Bucks and Montgomery counties, or
Bucks/Mont, will be used. The map depicts these areas. Each area has been assigned a color which
will be used throughout this report in graphs to depict that specific area.
Bucks/ Mont and Abington CB Area Demographics
Almost 544,000 people live in Abington's CB area. This represents 38% of all residents of Bucks and
Montgomery Counties combined.
Estimated Population: 2015
105,083
79,090
54,283
North Penn Indian Valley
92,159
82,330
79,029
Lower
Eastern
Abington
51,635
William
Tennent
Central Bucks
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
15
Upper Dublin
While Bucks/Mont anticipates a 1.3% increase in population between 2015 and 2020, Central Bucks
is expected to grow by 3.0% and North Penn by 2.7%, William Tennent, Lower Eastern, and
Abington are projected to increase only by .2, .2, and .4% respectively. Compared to the United
States, Bucks/Mont and Abington's CB populations are slower growing.
Projected Growth Rate 2015-2020
3.5%
3.0%
2.7%
2.3%
0.2%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
0.2%
0.4%
Lower
Eastern
Abington
1.3%
1.3%
Upper
Dublin
Bucks/
Mont
USA
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
Similar to Bucks/Mont, Abington's CB area is 52% female and 48% male and except for Lower
Eastern with a 54/46% female/male split, the gender distribution varies little across CB areas. Central
Bucks has a higher percent of youth ages 0-17 than the other Abington CB areas, Bucks/Mont and the
United States. William Tennent has a higher percentage of adults aged 65+ than other CB areas,
Bucks/Mont or the United States.
Age Distribution: 2015 Estimate
17.1%
17.3%
14.5%
13.7%
47.1%
46.2%
21.2%
22.8%
North
Penn
Indian
Valley
13.9%
19.1%
18.6%
18.0%
16.7%
14.7%
15.1%
14.5%
15.7%
14.4%
12.7%
45.8%
46.3%
45.1%
47.4%
49.5%
20.0%
20.7%
21.2%
21.5%
23.2%
William Central Lower Abington Upper
Tennent Bucks Eastern
Dublin
0-17
18-54
55-64
65+
Bucks/
Mont
USA
22.3%
13.5%
14.7%
48.1%
43.8%
19.2%
24.5%
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
16
In Bucks County, almost 28,000 residents identify themselves as Hispanic and in Montgomery
County more than 35,000 people, or 4% of the population is Hispanic. Although they share a
common language, each Hispanic community is culturally unique, and internally diverse by gender,
generation, class, and race.
The Asian community in Bucks County represents 4% of the total population (25,340 residents) and
is predominantly of Asian Indian descent. There are also residents from China, Korea, the
Philippines, and Vietnam, as well as Japan and other Asian countries. In Montgomery County, of the
53,000 residents with Asian backgrounds, the highest proportion are from India followed by people
of Korean, and Chinese descent. The remainder are from Vietnam, the Philippines, Japan, and other
countries.6
See the CHNA Special Population section on Immigrants and Refugees for more information on
Hispanics and Asians.
Compared to Bucks/Mont, Abington's CB area is slightly more likely to be White non-Hispanic
(79.9% vs. 80.4%). William Tennent is the least racial/ethnic diverse, with 89.4% of the population
identifying as non-Hispanic White. A higher proportion of Asian and Pacific Islanders live in North
Penn (15.4%), and a higher concentration of Black non-Hispanics (20.2%) live in Lower Eastern.
The Hispanic population ranges from a low of 3.2% in Upper Dublin to 4.7% in William Tennent.
Race/Ethnicity: 2015 Estimate
100%
80%
60%
40%
20%
0%
North
Penn
White Non-Hispanic
Indian
Valley
William
Tennent
Black Non-Hispanic
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Asian & Pacific Islander Non-Hispanic
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
17
Bucks/
Mont
USA
Hispanic
All Others
Social Determinants of Health
Social determinants of health are conditions in the environments in which people are born, live,
learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments
and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”
In addition to the more material attributes of “place,” the patterns of social engagement and sense of
security and well-being are also affected by where people live. Resources that enhance quality of life
can have a significant influence on population health outcomes. Understanding the relationship
between how population groups experience “place” and the impact of “place” on health is
fundamental to the social determinants of health. (Healthy People 2020)7.
To address social determinants of health, Healthy People 2020 uses a “place-based” approach that
consists of five key areas: economic stability (poverty, employment status, access to employment,
housing stability/homelessness); education (high school graduation rates, school environments,
enrollment in higher education); social and community context (family structure, social cohesion,
civic participation, incarceration); health and healthcare (access to health services including clinical
and preventive care, access to primary care including wellness and health promotion programs); and
neighborhood and built environment (crime and violence, access to healthy foods).
Abington's community assessment focuses on social determinants of health through a “community
benefit neighborhood-based” approach. The information about social determinants that follows
relates to the overall population. Social determinant issues that pertain to special populations will be
provided in the CHNA section for Special Populations.
Two indices measure social determinants of health in Abington's CB area of Bucks and
Montgomery Counties: County Health Rankings and the Community Need Index.
1) In the 2015 County Health Rankings for Pennsylvania, Montgomery County ranked 6th
highest and Bucks County ranked 12th among the 67 counties in the state using a variety of
measures including social and economic factors.8
2) Community Need Index - In 2005 Dignity Health, in partnership with Truven
Health, pioneered the nation’s first standardized Community Need Index (CNI). The CNI
identifies the severity of health disparity for every zip code in the United States and
demonstrates the link between community need, access to care, and preventable
hospitalizations. The CNI accounts for the underlying economic and structural barriers that
affect overall health. These barriers include those related to income, culture/language,
education, insurance, and housing. The CNI gathers data about a community’s socio-economy
(percentage of elderly living in poverty; percentage of the uninsured or unemployed, etc). A
score is then assigned to each barrier condition (with 1 representing less community need and
5 representing more community need). The scores are then aggregated across the barriers and
averaged for a final CNI score (each barrier receives equal weight in the average). A score of
1.0 indicates a zip code with the lowest socio-economic barriers, while a score of 5.0
represents a zip code with the most socio-economic barriers.9
18
The CNI score is highly correlated to hospital utilization – high need is associated with high
utilization. The CNI considers multiple factors that limit health care access, and therefore may be
more accurate than existing needs assessment methods. In addition, the most highly needy
communities experience admission rates almost twice as high as the lowest need communities for
conditions where appropriate outpatient care could prevent or reduce the need for hospital admission
such as pneumonia, asthma, congestive heart failure, and cellulitis. The chart below provides the CNI
for zip codes in Abington's CB area. Only one zip code, 19095 (Wyncote) in Lower Eastern, has a
CNI above 3.0.
CNI Scores by ZIP Code
North Penn
Zip
CNI
Code Score
18915 2.8
18936 1.6
19440 2.4
19446 2.4
19454 2.0
Indian Valley William Tennent
Zip
CNI
Zip
CNI
Code Score Code Score
18964 2.4
18966 1.2
18969 2.4
18974 2.4
19438 1.8
Central Bucks
Zip
CNI
Code Score
18914 1.4
18929 1.4
18932 1.4
18976 1.6
Lower Eastern
Zip
CNI
Code Score
19012 2.0
19027 2.8
19038 2.2
19046 2.2
19095 3.4
Abington
Zip
CNI
Code Score
19001 2.0
19006 2.0
19009 2.0
19040 2.2
19090 2.2
Upper Dublin
Zip
CNI
Code Score
19002 2.2
19025 1.4
19031 1.8
19034 1.8
19044 2.6
19075 1.6
19422 2.2
19436 2.4
19437 2.4
19477 1.4
Education
The level of education among residents in Abington's CB area varies. Residents living in Lower
Eastern and Upper Dublin are more likely to have college degrees or higher (50.3% and 56.3%
respectively) compared to Bucks/Mont (41.2%), while residents in Indian Valley and North Penn are
slightly more likely not to have graduated from high school (7.7% and 6.6% respectively) compared
to Bucks/Mont (6.5%). Compared to the United States, the residents in Abington's CB area are more
educated.
Adult Age 25+ Education Level: 2015 Estimate
100%
80%
60%
40%
20%
0%
North Penn
Indian
William
Central
Valley
Tennent
Bucks
No High School Degree
Some College/Assoc. Degree
Lower
Eastern
Abington
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
19
Upper
Bucks/
Dublin
Mont
High School Degree
Bachelor's Degree or Greater
USA
Education is one of the factors associated with health literacy. According to the U.S. Department of
Health and Human Services, health literacy "is the degree to which individuals have the capacity to
obtain, process, and understand basic health information and services needed to make appropriate
health decisions." Low literacy has been linked to poor health outcomes such as higher rates of
hospitalization, less frequent use of preventive services, and higher costs. Populations most likely to
experience low health literacy are older adults, racial and ethnic minorities, people with less than a
high school degree or GED certificate, people with low income levels, non-native speakers of
English, and people with compromised health status.10
Income and Poverty
"There are still poor in the Abington community."
"Being poor in Montgomery County: "what's wrong with them" stigmatization. If you are poor you are
marginalized."
Income in the Abington CB area is relatively high.
Average Household Income: 2015 Estimate
$130,026
$121,286
$103,602 $104,906
$103,246
$100,491 $94,074
$94,597
$74,165
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
USA
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
While the majority of the population enjoy household incomes of more than $75,000, there is poverty
in the community. Poverty can result in an increased risk of mortality, prevalence of medical
conditions and disease incidence, depression, intimate partner violence, and poor health behaviors.
20
Household Income Distribution: 2015 Estimate
100%
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William Central
Lower Abington
Tennent Bucks
Eastern
<$15K
$15-25K
$25-50K
$50-75K
Upper
Dublin
>$75K
Bucks/
Mont
USA
(2015 The Nielsen Company, © 2015 Truven Health Analytics Inc)
In 2015, the federal poverty level (FPL) threshold for a family/household of four was $24,250.11
Among Abington's CB neighborhoods, Lower Eastern residents are more likely to live below 100%
poverty than others living in Bucks/Mont.
% Below 100% Federal Poverty Guideline
7.4
5.8
5.7
4.4
4.4
4.6
4.3
North Penn
Indian
Valley
William
Tennent
Central
Bucks
4.3
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Communitycommons.org
Many subsequent data in this document compare rates between those living below 200% of the FPL
and those above. The percentage of people living below 200% of the FPL in each region is at least
twice that compared to people living below the 100% FPL. For example, while 4.4% of people in
North Penn were below the 100% FPL, almost 15% are below the 200% FPL.
21
% Below 200% Federal Poverty Guideline
17.5
14.9
15.4
14.6
16.2
15.8
11.5
9.5
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Communitycommons.org
In addition, there are people living in deep poverty, defined as below 50% of the federal poverty
level, in the Abington CB area.
% Below 50% Federal Poverty Guideline
3.8
2.0
North Penn
2.2
Indian
Valley
2.5
2.4
1.9
1.8
William
Tennent
Central
Bucks
2.0
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Communitycommons.org
Another way to measure economic welfare is to employ the Self-Sufficiency Standard. This
measures how much income a household of a certain composition in a given place needs to
adequately meet their basic needs—without public or private assistance. Using this measure, twice as
many Pennsylvania households lack sufficient income to meet their basic costs compared to the
federal poverty level. People of color have higher rates below the self-sufficiency level.12
22
% PA Households below SelfSufficiency: 2010
55%
48%
32%
21%
White
Asian
Black
Latino
While negative health effects resulting from poverty are present at all ages, children in poverty
experience greater morbidity and mortality than adults due to increased risk of accidental injury and
lack of health care access. Children’s risk of poor health and premature mortality may also be
increased due to the poor educational achievement associated with poverty. According to the 2015
County Health Rankings & Roadmaps, 19% of Pennsylvania children live in poverty.13 While the
proportion of poor children living in households below 100% FPL in Bucks/Mont areas is lower than
in Pennsylvania, it is higher than the all ages Bucks/Mont's population.
Children: % Below 100% Federal Poverty Guideline
7.8
7.0
4.0
North Penn
4.8
Indian
Valley
5.4
6.8
5.9
3.7
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Communitycommons.org
According to the Self-Sufficiency Standard, households with young children are the most likely to be
financially insecure.
23
% PA Households below SelfSufficiency: 2010
46%
35%
27%
20%
No children
With children Young children*
* youngest child < 6
Older
children**
** youngest child 6-17
In addition, 20% of children in both Bucks and Montgomery counties live in single parent
households. Although this proportion is significantly lower than for Pennsylvania (33%),14 it
represents a sizable number of adults and children in single-parent households who are at risk for
adverse health outcomes such as mental health problems (including substance abuse, depression, and
suicide) and unhealthy behaviors such as smoking and excessive alcohol use.
Access to Healthy and Affordable Food
Although Bucks and Montgomery counties are affluent, food insecurity affects approximately 10% of
the population and more than 15% of children according to Feeding America – Map the Meal Gap.
In terms of population in Abington's CB areas, this represents almost 54,000 individuals including
almost 17,000 children.15 Food insecurity is dispersed throughout the Abington CB area.16
24
Food insecurity, defined as limited access to sufficient nutritious food, impacts a child’s development
both in terms of brain development and growth, and has been shown to be related to increases in
childhood obesity. Children who experience food insecurity and hunger are more likely to require
hospitalization, be at risk of chronic health care conditions such as anemia and asthma, and be at
increased risk of oral health problems. In addition, food insecurity may affect children's ability to
fully engage in daily activities such as school and socializing with peers and they are more likely to
be behind academically. Behavioral challenges are also evident among children who experience food
insecurity. These children are at greater risk for truancy, and behavioral problems such as aggression
at school, hyperactivity, anxiety, mood swings and bullying.17
25
These health and behavioral risks may contribute to the cycle of poverty and future success as an
adult. Food insecure adults are more likely to be at risk for diabetes, hypertension, and high
cholesterol. Pregnant women who are food insecure are more likely to experience major depression,
have low weight babies, and experience birth complications compared to women who are food
secure. Seniors are also adversely affected by hunger.
Not surprisingly, a result of food insecurity is higher health care costs. According to a recently
published article by the Canadian Medical Association, households with low food security incurred
health care expenses that were 49% higher than those who were food secure. Among those with very
low food security (those who missed meals or ate smaller meals because they could not afford food) ,
health care costs were 121 % higher.18
Additionally, in a study of patients in an emergency department, food insecure patients were more
likely than food secure patients to:
 report a variety of chronic and mental health problems including obesity
 delay paying for medication to have money for food
 take medication less often because they could not afford more
 choose between buying food and medicine
 get sick because they could not afford to buy medicine19
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and food
stamps, according to Children’s Watch, are the “best medicine” to treat food insecurity. However,
according to a 2013 Pennsylvania report, there were 470,000 eligible residents who did not
participate in SNAP and only 56% of eligible Pennsylvanians received WIC benefits.20
Statewide participation in the WIC program declined by 2.7% to 245,424 in August 2015.21 Fewer
than 2% of Bucks and Montgomery county residents receive WIC benefits, with the highest
concentration of recipients in the Lower Eastern section of Abington's CB. In addition, 15% of
children in Bucks and 16% of children in Montgomery County qualify for the free lunch program.22
The proportion of children qualifying for free or reduced lunch is much higher in certain
communities: for example, 25.5% of North Penn School District and 19.4% of Souderton Area
School District were eligible.23
% Receiving WIC
3.4
2.2
1.3
1.0
0.1
0.2
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
PHMC Household Health Survey 2015
26
0.1
0.5
Abington
Upper
Dublin
Bucks/
Mont
As of August 2015 in Pennsylvania, almost 1.9 million residents received food stamps through the
Supplemental Nutrition Assistance Program (SNAP) and the number increased 2.4% from the
previous year.24 In April 2014, 6% of Bucks County and 6.5% of Montgomery County residents
received SNAP benefits, representing a .5% decline and 4.2% increase respectively in the number of
recipients compared to the previous year.25 In Abington's CB area, the percentage of people receiving
food stamps ranged from 2.6% in Upper Dublin to 9.9% in Central Bucks.
% Receiving Food Stamps
9.9
8.5
7.0
6.6
7.5
5.7
3.1
North
Penn
2.6
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
The percent of adults who reported cutting a meal due to cost is an indicator of food insecurity.
While most regions in the Abington CB area have low food insecurity rates (<3%), the rate in Central
Bucks is significantly higher.c
% Who Cut a Meal due to Lack of Money
8.8
4.5
2.6
2.0
0.4
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
1.5
0.0
0.6
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Although most of Montgomery County is within close proximity to one (or more) full service grocery
stores, many of the more densely populated boroughs do not have a full-service grocery store. A
c
For certain questions in the PHMC survey, the responses from Central Bucks are puzzling. Footnotes in this document
will explain results based on data from the 2 zip codes with sufficient sample sizes for analysis: Chalfont (zip code
18914) and Warrington (zip code 18976). Driving this high number is the more than 25% of Warrington (zip code
18976) residents reported cutting a meal.
27
recommendation of the Montgomery County Comprehensive Plan is that these places should
encourage grocery stores, farmers’ markets, community gardens, home gardens, and food safety net
providers within their borders to provide fresh fruit and vegetable options.26
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to access to healthy and affordable food include:







food insecurity especially affects high risk patients and women and children
lack of healthy food exacerbates substance abuse, depression, and anxiety conditions
those with mental health issues may not know or be aware of nutrition and healthy eating
habits
healthy foods are expensive and not always available in convenient locations; cheaper
foods can be unhealthy
people eat out more than they cook
lack of access to affordable foods is a well known contributor to obesity related issues for
low income and vulnerable populations
there are too many pizza shops
Recommendations include:
1)
2)
3)
4)
more local food retailers
local government should focus on safe walkable access to healthy food retailers
a list of community resources should include information on healthy food
turkey giveaways and meals for seniors
Employment and Job training
As of June 2015, unemployment in Bucks (4.7%) and Montgomery (4.3%) counties are among the
lowest in the metropolitan area. These rates are lower than the U.S. average of 5.5% and represent
decreases in unemployment of about 2% since 2013.27
Weekly wages in Montgomery County in Q1 2015 were the highest of any Pennsylvania county
($1,397). The Bucks County weekly wage at $930 was lower than the Pennsylvania average of
$1,031.28
Compared to the employed, those not working in Bucks/Mont are more likely to report their health as
fair or poor, and have diabetes, high blood pressure, or a diagnosed mental health condition. In
addition, unemployed adults are slightly more likely to smoke compared to employed adults.
Fair/Poor
Health
Status
Diabetes
High BP
Employed
7%
7%
21%
13%
12%
Not employed
25%
18%
46%
18%
13%
PHMC Household Health Survey 2015
28
Mental
Condition Smoker
The implications of poor health on labor market outcomes are enormous for patients, families,
employers and policy makers. Poorly managed health conditions have been associated with increased
absenteeism, poor productivity, decreased job retention, and fragmented work histories. In a survey
sponsored by Nationwide Better Health,29 85% of respondents reported that unplanned absences are
normally due to a health condition, either their own or that of a family member. Half of these
absences were due to a recurring health condition. Mental and physical health illnesses, personal
problems, the need to be with their families or job-related stress also increase lost productivity at
work. Absence management leads to a healthier workforce and keeps people on the job at full
strength to maximize a company’s productivity and profit.
For Abington CB area's vulnerable adults, finding a job with family-sustaining wages is only the first
hurdle on the path to economic stability. Because of physical and mental health challenges, a lack of
peer support and limited work experience, low skilled adults often find it difficult to not only obtain
jobs, but retain their jobs. Once employed, many residents in these communities need to receive ongoing counseling and support services to improve their work habits, manage work-related stress,
balance family and work obligations, and effectively manage chronic health conditions.
According to Healthy People 2020, public health infrastructure is fundamental to the provision and
execution of public health services at all levels. A strong infrastructure provides the capacity to
prepare for and respond to both acute (emergency) and chronic (ongoing) threats to the nation’s
health. Infrastructure is the foundation for planning, delivering, and evaluating public health. As
minority populations in Bucks and Montgomery counties and the United States increase, a more
diverse public health workforce will be needed. In many areas, Hispanics and African Americans are
underrepresented in the public health workforce. In addition, while there are Asian providers,
language barriers across the area's diverse Asian communities exist. According to Cohen, Gabriel,
and Terrell, increasing the racial and ethnic diversity of the health care workforce is essential for the
adequate provision of culturally competent care to our nation's burgeoning minority communities. A
diverse health care workforce will help to expand health care access for the underserved, foster
research in neglected areas of societal need, and enrich the pool of managers and policymakers to
meet the needs of a diverse populace. The long-term solution to achieving adequate diversity in the
health professions depends upon fundamental reforms of our country's precollege education system.30
There exists a growing literature related to the use of community health workers/navigators/coaches
(CHWs) to increase the diversity of the workforce and in care management, facilitation of transitions
of care, chronic disease management and bridging cultural divides. Interviews with organizations
serving immigrants shared the need to train members of limited-English speaking communities in
health professions including health care providers and community health workers. Developing a
recruitment and training program for CHWs has the potential to provide job opportunities for
minority populations and meaningful employment. It has also been shown to improve the quality and
outcomes of care.31
Recommendations include:
1) recruit people of color, especially for professional and leadership positions
2) recruit and retain individuals from various backgrounds
3) develop more connections with schools for workforce development
29
4) Develop hospital policies to maximize employee flexibility for issues related to FMLA,
skills acquisition, and organizational mission/service leave opportunities
5) Invest in time and education to develop motivational interviewing skills for health
professionals that will enhance shared decision making with patients.
Community Safety
The health impacts of community safety include the impact of violence on the victim, symptoms of
post-traumatic stress disorder (PTSD), psychological distress due to chronic exposure to unsafe living
conditions and various other health factors and outcomes including birth weight, diet and exercise,
and family and social support. Exposure to crime and violence has been shown to increase stress,
which may exacerbate hypertension and other stress-related disorders and behaviors such as smoking
in an effort to reduce or cope with stress. Exposure to violent neighborhoods has been associated with
increased substance abuse and sexual risk-taking behaviors as well as risky driving practices.20
Violent crime is represented as an annual rate per 100,000 population. Violent crimes are defined as
offenses that involve face-to-face confrontation between the victim and the perpetrator, including
homicide, forcible rape, robbery, and aggravated assault. Compared to the Pennsylvania average
violent crime rate (357), Bucks (112) and Montgomery (182) counties are relatively safe places.
However, the violent crime rates in Bucks and Montgomery counties equates to more than 2,000
victims annually.32 Statewide, the number of violent crimes decreased 11% from 2009 to 201333 and
in Abington Township, the number of major crimes (violent crimes, burglary, theft, auto theft and
arson) declined 12.3% between 2010 and 2014.34
Domestic violence is also a concern in the community. AJH and the Women's Center of Montgomery
County offer free and confidential counseling, legal advocacy, shelter referrals and support groups; in
FY 2015, Abington Hospital served more than 400 victims of domestic violence and the Women's
Center received almost 6,100 hotline calls. The specialized forensic nurse examiner program at
Abington Hospital is the only program in Montgomery County providing 24/7 availability of
specially trained and certified Sexual Assault Nurse Examiners. For the 9 month period ending
August 31, 2015, this program provided individualized physical and emotional care for 76 victims
ranging in age from 11 to 70. The vision of an expanded forensic team includes caring for all victims
of crime such as child abuse, elder abuse, domestic violence, and other victims of trauma.
Neighborhoods with high violence encourage isolation and therefore inhibit the social support needed
to cope with stressful events. New research from Penn Medicine focusing on 10-24 year old primarily
African American males, suggests that where they go and how they get there can mitigate or increase
the risks of exposure to violence by gunfire and other weapons.35 Additionally, exposure to the
chronic stress of community violence and unsafe built environment contributes to the increased
prevalence of certain illnesses, such as upper respiratory illness and asthma.
In Abington's CB areas, between 11 and 26% of people reported being uncomfortable visiting a
nearby park or outdoor space during the day. These concerns are likely to restrict physical activity.d
d
The Warrington community in Central Bucks again is an outlier, with 36% reporting being uncomfortable visiting a
nearby park or outdoor space during the day. Although many respondents in Warrington are clearly concerned about their
30
% Uncomfortable Visiting a Nearby Park or Outdoor Space
During the Day
26.0
17.9
15.2
14.2
11.3
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
17.6
13.2
Abington
11.5
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Among the community safety goals articulated in Montgomery County's Comprehensive plan are:



right-sized roads, traffic calming, green streets, and sidewalks
better walkability by installing sidewalks on county roads in appropriate locations when the
roads are rebuilt and walkability audits with local communities
bike-friendly improvements to roads in cooperation with PennDOT, bicycling organizations,
and local municipalities
Programs are available at the local level. For example, the Abington Township Police Department
has multiple offerings to promote community safety and wellbeing:36
safety in public outdoor spaces, crime data indicate that Warrington is a relatively safe place, with crime rates below the
county average for all categories (http://www.paucrs.pa.gov/ibi_apps/WFServlet?IBIF_ex=RUREP01&MAPAREA=09)
2013
Warrington
Bucks County
Rate per 100,000 Population
Criminal Homicide
0
1
Sex Related Offenses
30
50
Robbery
34
41
Assaults
170
229
1,621
2,683
0
8
Drug Violations
195
297
Other Alcohol Crimes
382
547
Property Offenses
Arson
In one recent analysis using crime data from the FBI, Warrington is ranked the 76th safest community with a population
over 10,000 in Pennsylvania. As a comparison, Warminster and Abington Townships are ranked 99 and 126 in the same
study. (http://www.valuepenguin.com/2015-safest-cities-pennsylvania-study)
31








the C.A.P.T program, Citizens and Police Together, is dedicated to reducing crime and fear of
crime
the Town Watch program to make neighborhoods safer
Away Home Notification program, in which officers periodically check properties when
residents are away for an extended period of time
the D.A.R.E. curriculum (Drug Abuse Resistance Education) in all district facilities and 5
private schools located in the township
school resource officers in Abington middle and high schools
police officers working with residents and businesses to promote crime prevention
C.A.R.E. program, Crimes Against the Retired and Elderly, teaches seniors how to protect
themselves
Victim services unit, to assure victims are treated with respect and dignity
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to community safety included:

Interpersonal violence
o Lack of shelters and undesirable locations of shelters for domestic violence victims
o Domestic violence affects children and adults; the mental health issues are just
beginning to be recognized
o Vulnerable senior abuse includes financial and poor care (e.g. bed sores, infections)

Drug use
o Access to gateway drugs among youth aged 14-18 (marijuana and alcohol)

Injury/Trauma
o Helmets needed for children's bicycle safety
o Falls prevention for seniors
o Burn prevention for all
o Need for safe walking environments
o Trauma related to transportation issues (distracted driving, DUI) does not receive
enough attention; education and prevention are needed

Need for more constructive activities for youth and seniors
o After school and summer programming for kids/youth in area
o " need something to do… if not they get into trouble"
o Senior centers
Recommendations included:
1) Utilize Philly Rising initiative strategies which address violence by reducing substance
abuse among youth (focus is on reducing use of entry drugs such as alcohol and
marijuana)
2) Explore “walking bus” intervention to improve student safety
32
3) More education on domestic violence. Awareness that missed appointments may be
domestic violence related. Utilize AJH domestic violence social worker who knows the
system, works well with security, and is successful obtaining Protection from Abuse
orders.
4) Aldersgate Counseling Services, Police Athletic Leagues, and municipal sports programs
are good resources for activities for kids
5) Countywide Youth Aid Panel needed for 18 to 25 year old first offenders
6) Coordinated efforts of the Abington Police Department and Abington Jefferson Health
to publicize programs such as ID theft, bike safety and other themes
7) Utilize Montgomery County Health Department Distracted Driving Initiatives
Family and Social Support
"Social support stems from relationships with family members, friends, colleagues, and
acquaintances. Social capital refers to the features of society that facilitate cooperation for mutual
benefit, such as interpersonal trust and civic associations. Individual social support and cohesive,
capital-rich communities help to protect physical and mental health and facilitate healthy behaviors
and choices.
Socially isolated individuals have an increased risk for poor health outcomes. Individuals who lack
adequate social support are particularly vulnerable to the effects of stress, which has been linked to
cardiovascular disease and unhealthy behaviors such as overeating and smoking in adults, and
obesity in children and adolescents.
Residents of neighborhoods with low social capital are more likely to rate their health status as fair
or poor than residents of neighborhoods with more social capital, and may be more likely to suffer
anxiety and depression. Neighborhoods with lower social capital may be more prone to violence than
those with more social capital and often have limited community resources and role models. Socially
isolated individuals are more likely to be concentrated in communities with limited social capital.
Individuals with higher educational attainment and higher status jobs are more likely to have greater
social support than those with less education and lower incomes. Adults and children in single-parent
households, often at-risk for social isolation, have an increased risk for illness, mental health
problems and mortality, and are more likely to engage in unhealthy behaviors than their
counterparts.
Adopting and implementing policies and programs that support relationships between individuals
and across entire communities can benefit health. The greatest health improvements may be made by
emphasizing efforts to support disadvantaged families and neighborhoods, where small improvements
can have the greatest impacts."37
"In the past everyone knew their neighbor and neighborhood… today it is much different with two
parents working or single parent households; there used to be town watch. What happened to
"Welcome Wagons? (key informant)"
Connectedness to their neighborhoods varies among Abington's CB areas, with residents of North
33
Penn and Central Bucks more likely to disagree or strongly disagree with the statement “ I feel I
belong in my neighborhood.”e
%Who Feel They Do Not Belong in Their Neighborhoods
12.2
11.6
10.4
9.6
7.3
6.7
5.1
North
Penn
Indian
Valley
5.1
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Although a higher proportion of residents of North Penn and Central Bucks do not feel they belong in
their neighborhoods, they participate in organizations at a rate higher than the Bucks/Mont average.
Abington residents, who feel most connected with their neighborhoods, have less involvement with
organizations.
% Currently Participating in Organizations
11.3
15.7
17.6
19.3
15.5
13.9
17.8
45.4
44.7
39.3
38.1
42.1
34.0
47.7
43.3
39.6
43.1
42.5
42.4
North Penn
Indian
Valley
52.2
William
Central
Lower
Tennent
Bucks
Eastern
No Organizations
1-2 Organizations
12.7
38.9
48.2
34.5
Abington
Upper
Dublin
3+ Organizations
Bucks/
Mont
PHMC Household Health Survey 2015
Residents of North Penn and Indian Valley report a higher percent of neighbors who are never willing
to help each other. Although residents of Central Bucks feel like they do not belong in their
neighborhoods, they report the highest willingness to help each other.f
e
Residents of Warrington within Central Bucks are driving this data point, with 23.4% of respondents feeling like they do
not belong in their neighborhood.
f
Warrington residents report that neighbors always help each other at a rate lower than other Central Bucks communities.
34
% Neighbors Willing to Help Each Other
50
40
30
20
10
0
North Penn
Indian
Valley
William
Central
Lower
Abington
Tennent
Bucks
Eastern
Never
Rarely
Sometimes
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Community members in Lower Eastern report the highest rate of working together.
% Neighbors Who Worked Together
68.7
63.6
60.7
50.7
North
Penn
46.7
50.0
Indian
Valley
William
Tennent
52.8
Central
Bucks
Lower
Eastern
Abington
51.8
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Almost one-third of Bucks/Mont residents provide care for family or friends. In William Tennent,
Central Bucks, and Upper Dublin, approximately 38% of residents reported caring for a family
member or friend in the past month. About 25% of people living in North Penn, Indian Valley, and
Abington assisted family or friends in the past month.
35
% Providing Care to Family/Friend in the Past Month
38.4
25.2
24.5
North
Penn
Indian
Valley
38.4
38.0
35.6
31.7
26.4
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
The percentage of adults aged 60+ who provide care to family or friends is slightly less than that of
the total adult population, except in Eastern Montgomery (note areas are consolidated due to
sampling size).
% Age 60+ Providing Care to Family/Friend
During the Past Month
38.1
34.9
31.1
24.2
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to family and social support included:

Support
o Elderly are taking care of themselves. Care-giving a major issue as well.
o Caregiver is usually an adult daughter or son of an older adult. Caregivers need
support: they lack sleep; do not take care of themselves; physically hurt themselves in
the physical care of another; are deficient in their knowledge.
o Caregivers need time to learn about resources during an acute episode. Need to
connect to community supports/resources for support such as food, care-giving, and
transportation.
o Waiting lists are a concern.
36

Caregiver is usually an adult daughter or son of an older adult. Caregivers need support: they
lack sleep; do not take care of themselves; physically hurt themselves in the physical care of
another; are deficient in their knowledge.
Recommendations included:
1) Virtual Care [new technologies]. Electronic medical record in the future may have
more linkages. Systems that talk to each other.
Built and Natural Environment
The public health community has become increasingly aware that the design of the built environment
can have a major impact on the health of the public. For example, people living in communities with
convenient, safe walking paths, bike lanes, bike racks, parks/playgrounds that are in good condition,
and access to healthy, affordable food sources may be more physically active and have healthier diets.
Conversely, poorer health indicators may be expected among residents of communities with high
crime rates, few parks or walking paths, numerous alcohol and tobacco outlets, and little access to
fresh food. The powerful influence of the built environment on health suggests that public health
practitioners should be involved in planning and policy decisions related to land use, zoning and
community design. Health practitioners can serve an essential role in collaborating with other
professionals and working alongside neighborhood residents to create and promote healthy
communities. Health practitioners need to engage in actions that support: (1) assessing the health
impact of land use and community design options before decisions are made as well as after
improvements are implemented; and (2) policymaking on issues related to the built environment to
ensure protection from toxins, access to healthy food outlets, places to walk and recreate, and other
health promoting environments.38
European research suggests that people who live proximate to areas of greenery are 3 times more
likely to engage in physical activity and 40% less likely to be overweight.39 A 2012 study in
Philadelphia conducted by researchers from the University of Pennsylvania40 found that greening
vacant lots may affect health and safety. Although vacant lots are not a significant issue in the
suburbs, the study findings apply in Abington's CB areas. Researchers found significantly lower
levels of vandalism and stress among residents, as well as significantly higher levels of physical
activity among residents in areas where abandoned lots where cleaned and greened. Green space may
also, according to the research, build social ties that are important for health.
The availability of places to recreate and exercise and the availability of fresh produce can promote
the health of residents.41 Parks, recreation centers, schoolyards, and community gardens that are in
good repair all help foster a sense of community, which leads to strong, safe neighborhoods.
Montgomery County's new comprehensive plan, Montco 2040: A Shared Vision, addresses many
issues related to health. Among its goals and success measures are:


Improve transportation quality and expand options for county residents and workers
Reduce pedestrian/vehicle and bike/vehicle accidents; increase pedestrian and bike
commuters
Provide more opportunities for residents to exercise and have healthy lifestyles
37


Increase park users, increase farmers markets and farms
Support housing choices and opportunities to meet the needs of all people
Approve new municipal ordinances allowing affordable housing, accessory apartments, and
special needs housing
Enhance community character and protect neighborhoods
Reduced emergency response time 42
In addition, Montgomery County's Walkability and Your Community Health, Safety, and Economics
report offers compelling evidence why walking is important to health, why walkable communities are
desirable, and funding opportunities that communities can utilize to make their community friendlier
for pedestrians and cyclists.43
38
Health Care Access
Health care access is determined by multiple factors including health insurance, transportation,
language and literacy, and cultural competency.
Health Insurance
Under the Affordable Care Act, millions of Americans became eligible for new coverage
opportunities in 2014. As of September 2015, 17.6 million uninsured Americans gained coverage in
large part to the Affordable Care Act and 10.5 million more are uninsured but eligible for
Marketplace coverage. Enroll America research found that nearly half of the uninsured lack
confidence in choosing a health insurance plan.44
The Healthy People 2020 goal is insurance for everyone. In Bucks/Mont, 5.4% of adults aged 18-64
are uninsured and 2% of children lack health insurance. The percent of adults aged 18-64 without
insurance ranges from 1.6% in Lower Eastern to 9.3% in North Penn. Black and Hispanic residents,
and those age 18-34, are more likely to be uninsured.45
% Insured Adults, Ages 18-64
Healthy People 2020 Target = 100%
90.7
94.8
95.5
98.1
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
98.4
92.0
Lower Abington
Eastern
97.4
94.6
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
% Insured Children
Healthy People 2020 Target = 100%
99.4
97.7
98.3
96.5
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
PHMC Household Health Survey 2015
39
Bucks/Mont
Cost and employers not offering coverage were the most frequent reasons given for not having
insurance. Note: Only Bucks/Mont data is presented because the sample sizes of uninsured
respondents in the Abington CB areas is too small for meaningful analysis.
Bucks/Mont
Job status change
7.3
Ineligible due to age/left school
1.7
Employer doesn't offer coverage
12.0
High cost
50.7
Other *
28.3
* includes insurance company refused
coverage; objections to ACA; difficulties using
healthcare.gov; death or divorce
PHMC Household Health Survey 2015
On average, about a third of the population in Bucks/Mont and Abington's CB areas enrolled for
health insurance through Healthcare.gov. Fewer people in Lower Eastern, the area with the highest
health insurance coverage rate, used Healthcare.gov, perhaps because they were already covered with
satisfactory insurance. Between November 15, 2014 and February 22, 2015, 33,357 and 39,695
people in Bucks and Montgomery counties respectively selected Marketplace plans (note: not all of
these people were uninsured; they may have switched plans).
As part of the Get Covered America initiative, Abington and Lansdale Hospitals in partnership with
Enroll America sponsored open enrollment opportunities in December 2015 and January 2016 to
support people applying for coverage.
% Enrolled through Healthcare.gov
44.9
32.9
33.2
36.8
36.1
32.8
33.6
Upper
Dublin
Bucks/
Mont
15.8
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
PHMC Household Health Survey 2015
The majority of residents in Abington's CB area have insurance through work, school, or a union.
40
Type of Insurance (can have more than one)
North
Penn
Indian
Valley
William Central Lower
Upper
Abington
Tennent Bucks Eastern
Dublin
Bucks/
Mont
Work, school, union
67.1
52.3
58.6
70.7
64.9
56.0
58.6
59.4
Self or family (including w gov
assist)
43.0
50.7
60.8
54.6
60.1
58.6
54.3
52.2
Medicare A
16.7
28.9
35.9
24.3
22.3
28.7
31.3
28.2
Medicare B
18.0
26.1
34.8
18.4
21.1
30.3
28.2
27.3
Medicaid
4.9
12.9
6.9
7.7
3.9
5.7
2.7
7.4
Champus or Tricare
0.5
4.1
5.8
1.1
4.3
1.0
1.9
2.0
Other group
27.9
25.4
26.3
21.0
32.0
35.4
24.5
24.7
PHMC Household Health Survey 2015
Affordability of health insurance premiums, co-pays, and deductibles is a concern for the majority of
residents in Abington's CB areas. Residents of Central Bucks who enrolled most often through
Healthcare.gov, reported the least difficulty finding plans with affordable premiums, co-pays, and
deductibles.g This contrasts to the 70+% of people living in Abington who reported that finding an
affordable health plan was very difficult.
% Finding a Plan with Affordable Monthly Premiums
100%
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Not at all difficult
8.7
27.3
32.2
68.1
11.7
10.2
46.6
27.5
Somewhat difficult
41.4
30.4
31.2
9.1
24.0
18.2
32.0
31.2
Very difficult
49.9
42.3
36.6
22.8
64.3
71.7
21.3
41.4
PHMC Household Health Survey 2015
g
More than 75% of respondents from wealthier Chalfont and less affluent Warrington reported finding affordable
monthly premiums and affordable co-pays and deductibles was "Not at all difficult".
41
% Finding a Plan with Affordable Copays and Deductibles
100%
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Not at all difficult
28.0
34.7
26.5
67.2
17.2
17.1
48.2
29.6
Somewhat difficult
30.9
20.7
36.9
5.6
20.4
11.4
28.2
27.0
Very difficult
41.1
44.6
36.6
27.2
62.4
71.4
23.6
43.4
PHMC Household Health Survey 2015
Although more than two thirds of Central Bucks residents reported that finding an insurance plan
with affordable premiums, co-pays and deductibles was not at all difficult, residents from this area
also reported the greatest frequency of not seeking care due to cost, suggesting a group of residents
who are struggling financially.h
% Sick Who did not Seek Care Due to Cost
11.6
9.7
7.5
North
Penn
Indian
Valley
9.9
10.2
Lower
Eastern
Abington
9.1
9.1
Upper
Dublin
Bucks/
Mont
5.9
William
Tennent
Central
Bucks
PHMC Household Health Survey 2015
The majority of people in Bucks/Mont have prescription coverage (88.4%).
h
Warrington residents did not seek care due to cost at a rate almost 3 times higher than Chalfont residents.
42
% with Prescription Coverage
94.0
90.3
90.2
91.8
91.4
88.4
85.7
82.0
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Although residents of Lower Eastern report the highest rate of prescription coverage, they also report
the highest rate for not obtaining medication due to cost.
% Who Did Not Obtain Prescription Medicine due to Cost
17.6
16.0
16.0
13.8
10.5
10.0
North
Penn
14.4
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
12.5
Bucks/
Mont
PHMC Household Health Survey 2015
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to health insurance and access to care include:

Cost for services for the uninsured and under-insured is prohibitive for many
o high co pays/ high deductible; out of pocket expenses an issue
o "Economics" is a huge crisis
o Uninsured, underinsured, and undocumented adults cannot pay for primary care.
o The inability to afford medications leads to mismanagement and risk of rehospitalization
o Affordable access for immunizations is more challenging since Montgomery County
Health Department decreased availability of free vaccine programs
o There is insufficient insurance coverage for acute renal care; Medicare pays only for
chronic care
43
Recommendations included:
1) Increase social workers to assist individuals in enrollment in Medicaid expansion programs,
insurance exchanges, pharmacy assistance resources, and other government programs
2) Evaluate the medical access program (sample Phoenixville Foundation)
3) Educate about pharmacy assistance resources such as pharmaceutical companies assistance
programs and Walmart
Transportation
Fewer than 5% of people in Abington's CB areas cancelled a doctor appointment due to a
transportation problem. Although not an issue for the majority of the population, such cancellations
may lead to negative health outcomes. For those in need, it is "harder and harder to get to
appointments or keep existing ones."
% Didn't Go to a Needed Doctor Appointment Due to
Transportation Problems
5.2
3.8
5.2
5.2
5.3
Upper
Dublin
Bucks/
Mont
3.3
1.4
1.0
North
Indian
William
Central
Penn
Valley
Tennent
Bucks
PHMC Household Health Survey 2015
Lower
Eastern
Abington
Montgomery County, through its Department of Public Safety, operates the 9-1-1 system; coordinates
public safety services among police, fire, and emergency medical responders; and provides public
safety training. According to key informants, there are 68 EMS companies in Bucks County and at
least 20 ambulance agencies in the Montgomery County that are licensed as for profit transportation
ambulance organizations. For Bucks County Medical Assistance clients enrolled in the transportation
program, Bucks County Transport provides free transportation to any health care service that is
covered by Medical Assistance, including appointments with doctors, dentists, psychologists or
psychiatrists, drug and alcohol treatment clinics, pharmacies for prescriptions, hospital outpatient
services, and medical equipment suppliers. In Montgomery County, TransNet provides similar nonemergency transportation for Medical Assistance clients who are traveling to routine medical
appointments. The TransNet program also reimburses costs for using public transportation or
mileage, tolls, and parking if a private vehicle is used.
44
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to health care access and transportation include:


Cost of transportation for public transportation
o New SEPTA fare increase will negatively affect patients.
o It takes resources and navigation to get the patients to their appointment. SEPTA
fares, trans-net, and taxi cab vouchers are needed
Convenience
o Isolated seniors are in need of transportation
o Public transportation is a need for Asian patients coming from Philadelphia on the bus.
Recommendations included:
1) Transportation to support groups
2) Explore collaboration/partnership with PTMA transportation pilot program
Literacy
Health literacy is a stronger predictor of individual health status than age, income, employment status,
education level or racial/ethnic group.46 Inadequate health literacy, as measured by reading fluency,
independently predicts all-cause mortality and cardiovascular death among community dwelling
elderly persons.47 Health literacy also contributes to disparities associated with race/ethnicity and
educational attainment in self-rated health and some preventive measures.48 Race/ethnicity (African
American and Latino/Hispanic), age (older than 65), not completing high school, poverty, and not
speaking English prior to entering school have also been associated with lower literacy levels
(NAALS, 2003).49 Older adults are disproportionately more likely to have below basic health literacy
than any other age group. Almost two-fifths (39 percent) of people age 75 and over have a health
literacy level of below basic compared with 23% of people age 65–74 and 13% of people age 50–
64.42 (NAALS, 2003).
Low patient literacy is associated with limited disease-related knowledge and self- management, poor
adherence to treatment plans, and a 30-50% increased likelihood of hospitalization. Preventable
hospital admissions are also associated with poor health literacy.50 The Joint Commission’s National
Patient Safety Goals specifically address communication issues related to provider-patient
interaction.51
The health literacy of patients is often underestimated by health care providers and may not even be
considered as a factor in patient care.52, 53 The safety of patients cannot be assured without mitigating
the negative effects of low health literacy and ineffective communications on patient care. However,
there is more to health literacy than understanding health information. Health literacy also
encompasses the educational, social, and cultural factors that influence the expectations and
preferences of individual, and the extent to which those providing healthcare services can meet those
expectations and preferences.
45
In addition, the growing prevalence of chronic conditions and an aging population requires even more
attention to effective strategies to address health literacy. Patients with poor health literacy have a
complex array of communication difficulties, which may affect health outcomes. Such patients report
worse health status and have less understanding about their medical conditions and treatment; they
may have increased hospitalization rates. Professional and public awareness of the health literacy
issue must be increased, beginning with education of medical students and physicians and improved
patient-physician communication skills.54
Many experts suggest that low-literate adults should be educated using simple language geared to the
layperson, and using teach-back techniques to confirm patient understanding, as well as visual
methods including pictures, multimedia, use of pill-boxes, and graphic medication schedules.55
Recommendations included:
1) "Educate staff first then make changes to how we do things."
Cultural Competence and Language
"Non English speaking patients, with their diverse cultural background, may not fit into our hospital
blue print." (key informant)
" Needs go beyond language issues alone." (key informant)
"Lack of cultural sensitivity is inhibiting the road to wellness" (key informant)
"Some residents still feel that there are racial prejudices against African Americans, e.g., perception
of lack of diversity in leadership, physicians treating them differently, management treating them
differently." (key informant)
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come
together in a system, agency, or among professionals that enables effective work in cross-cultural
situations. 'Culture' refers to integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic,
religious, or social groups. 'Competence' implies having the capacity to function effectively as an
individual and an organization within the context of the cultural beliefs, behaviors, and needs
presented by consumers and their communities.56
Assuring cultural competency is one of the main ingredients in closing the disparities gap in health
care and is the way patients and doctors can come together and talk about health concerns without
cultural differences hindering the conversation, but enhancing it. Health care services that are
respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of
diverse patients can help bring about positive health outcomes.
Culture and language may influence: health, healing, and wellness belief systems; how illness,
disease, and their causes are perceived by the patient/consumer; their attitudes toward health care
46
providers; and the delivery of services by a provider who looks at the world through his or her own
limited set of values, which can compromise healing for patients from other cultures.
The increasing population growth of racial and ethnic communities and linguistic groups, each with
its own cultural traits and health profiles, presents a challenge to the health care delivery. The
provider and the patient each bring their individual learned patterns of language and culture to the
health care experience which must be transcended to achieve equal access and quality health care.
As described above, Abington's community benefit area serves increasingly diverse communities
including immigrants and a growing elderly population. As a result of the 2013 Community Health
Needs Assessment, AJH assembled a Cultural and Linguistically Appropriate Education and
Materials team to develop and implement an action plan focused on interpreters, document
translation, cultural competence, and project management. One project was to make the AJH clinics
brochure available in Spanish and Korean. The team also created a database of health websites of
multicultural translated health education and an intranet inventory of AJH's almost 100 patient
education and financial information documents translated into Korean, Spanish and Portuguese for
use by hospital staff and medical residents. In addition, a team comprised of diversity and nursing
leadership taught classes about cultural competence based on the JCAHO “One Size Does Not Fit
All” framework. Included in the classes was education on special populations: the deaf, East Indian,
bariatric, geriatric, Muslim, Korean, and Portuguese. More than 300 staff and medical residents
attended these classes which addressed health beliefs, expression of pain, male/female caregivers,
death, childbirth, and dietary habits.
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to culture and language:

Communication
o Hospital staff lack cultural competency skills; there is a racial divide
o Language is a barrier for the Korean community, especially for education on diseases,
prevention, and health insurance issues

Culture
o Some immigrants from Mexico and Central America are afraid of going to doctor,
fearing outcomes and cost. Language and culture are barriers.
o Asian patients utilize the hospital system differently than other Abington CB area
residents. Asians use more clinics and ER visits verses primary care physician visits.
Interpretation
o There are limited skilled home care agencies that provide bilingual services to the
Korean community. "Needs go beyond language issues alone."
o There are opportunities to improve our interpretation to English as a Second Language
patients.

Recommendations included:
1) Invite members of the community for ongoing input to develop a formal strategy for
how to move forward
47
2) Need more tailored education with trans-cultural consideration
3) Need more education regarding the medical system and available financial assistance for
immigrants; educational programs are planned for a future community center to house
such programs to serve the Latino population in and near Hatboro
4) Need more social workers bilingual in Korean who are knowledgeable about benefits,
especially for older Korean Americans
48
Health Status
Mortality
Bucks and Montgomery counties rank 13th and 4th respectively in Pennsylvania in terms of
longevity.57
With the exception of accidents and suicide, age adjusted mortality rates per 100,000 population
decreased for all causes between 2002 and 2012. Values are not been shown when counts are less
than 10.58
Cause
Bucks Montgomery Bucks Montgomery Bucks # Montgomery
Rate
Rate 2012
Rate
Rate 2002
Deaths
# Deaths
2012
2002
2012
2012
All
Malignant Neoplasms
Heart Disease
Cerebrovascular Disease
Accidents
Chronic lower
respiratory disease
Diabetes
Nephritis
Influenza and
pneumonia
Septicemia
Suicide
Homicide
HIV/AIDS
Colorectal Cancer
Lung & Bronchus
Cancer
Breast Cancer
Prostate Cancer
664.8
160.8
130.4
32.6
40.2
32.9
649.2
155.3
143.4
44.3
35.1
30.2
854.4
197.7
217.3
62.1
32.9
52.1
801.9
196.0
203.8
63.4
25.0
38.7
5,333
1,288
1,085
266
266
267
7,124
1,631
1,645
512
329
329
16.8
11.9
10.3
16.5
13.6
10.7
17.9
18.2
20.1
16.7
17.3
15.2
137
99
87
177
152
116
10.0
11.9
13.7
40.0
10.5
10.0
2.0
1.4
13.9
38.2
20.2
8.9
23.1
47.4
18.3
9.9
3.5
2.8
19.1
50.7
83
79
9
3
109
320
113
88
15
12
146
394
13.5
16.1
12.2
17.0
17.3
32.8
15.7
34.6
109
51
128
73
Non-Hispanic blacks have the highest mortality rates overall and for heart disease, septicemia, and
cerebrovascular disease. Sample sizes for many other causes of death were too small.
Non-transport accidents and suicide is the major cause of death among 15 to 24 year olds, and both
are the leading causes of death among the 25-44 and 45-64 age groups. Montgomery County ranks in
the least favorable quartile in the Center for Disease Control's (CDC) CHSI comparison to peer
counties for all age motor vehicle and unintentional (including motor vehicle) deaths. 59
49
Top Causes of Death by Age Group
Age Group
Top Causes of Death in Montgomery County, 2011
15-24
Non-transport accidents
Motor vehicle accidents
Intentional self-harm (suicide)
Homicide
Malignant neoplasms
Non-transport accidents
Malignant neoplasms
Intentional self-harm (suicide)
Motor vehicle accidents
Heart disease
Malignant neoplasms
Heart disease
Non-transport accidents
Intentional self-harm (suicide)
Heart disease
Malignant neoplasms
Mental and behavioral disorders
Cerebrovascular disease
Chronic lower respiratory diseases
Alzheimer’s Disease
Non-transport accidents
Diabetes mellitus
Influenza and pneumonia
25-44
45-64
65+
2014 Montgomery County Health Department 2014 Annual Health Statistics Report
Although cancer mortality is below the Healthy People 2020 goal for most cancers, according to the
CHSI comparison to peer counties, Bucks County is in the least favorable quartile for cancer
morbidity and Montgomery County is in the least favorable quartile for cancer mortality.
In Bucks and Montgomery counties, lung and bronchus cancer mortality rates are lower than the
Healthy People 2020 goal for lung cancer deaths. Note that this is not an "apples to apples"
comparison.
50
Bronchus and Lung Cancer Age-Adjusted Death Rates
per 100,000 Population
Bucks
48.3
43.0
41.9
2010
Montgomery
41.7
HP 2020 Goal = 45.5
40.0
2011
38.2
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Breast cancer mortality rates were higher than the Healthy People 2020 goal.
Female Breast Cancer Age-Adjusted Death Rates per
100,000 Population
Bucks
25.4
23.4
Montgomery
24.5
2010
HP 2020 Goal = 20.7
24.4
24.3
2011
21.7
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Male prostate cancer mortality rate was lower than the Healthy People 2020 goal.
Male Prostate Cancer Age-Adjusted Death Rates per
100,000 Population
Bucks
19.4
17.4
2010
20
Montgomery
18.7
2011
Pennsylvania Department of Health Epidemiologic Query and Mapping System
51
HP 2020 Goal = 21.8
17
16.1
2012
In 2011 and 2012, the colorectal cancer mortality rates were lower than the Healthy People 2020 goal
in both Bucks and Montgomery counties.
Colo-rectal Cancer Age-Adjusted Death Rates per
100,000 Population
Bucks
15.0
Montgomery
HP 2020 Goal = 14.5
14.4
13.9
13.7
12.7
12.6
2010
2011
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Melanoma mortality rates were higher than the Healthy People 2020 goal in Bucks County in 2010
and 2011, but lower than the Healthy People 2020 target in both counties in 2012.
Melanomas of the Skin Cancer Age-Adjusted Death
Rates per 100,000 Population
Bucks
2.9
Montgomery
HP 2020 Goal = 2.4
2.7
1.9
2010
1.8
2011
1.8
1.4
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Deaths related to diabetes mellitus in Bucks and Montgomery counties compare favorably to the U.S.
median mortality rate. This comparator is used instead of the Healthy People 2020 rate because
Healthy People 2020 diabetes-related mortality data are derived from the multiple-cause-of-death
files which include all mentions of diabetes on the death certificate and are approximately three times
higher than if diabetes only as the underlying cause is counted.
52
Diabetes Mellitus Age-Adjusted Death Rates per
100,000 Population
Bucks
16.5
12.3
Montgomery
2010
16.8
13.9
13.4
US Median = 24.7
2011
16.5
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Heart disease mortality rates in both counties are lower than the Healthy People 2020 target.
Coronary Heart Disease Age-Adjusted Death Rates per
100,000 Population
Bucks
102.5
84.2
HP 2020 Goal = 103.4
95.7
93.2
80.7
2010
Montgomery
74.0
2011
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
The Healthy People 2020 goal for age-adjusted stroke mortality is 34.8. Mortality for the broader
category of cerebrovascular diseases is displayed below, and was lower than the stroke mortality goal
for Bucks and Montgomery counties is 2012. In Bucks County, the cerebrovascular mortality rate
increased between 2010 and 2012. The Centers for Disease Control Summary Report ranks
Montgomery County stroke deaths in the least favorable quartile when compared to peer counties.60
53
Cerebrovascular Diseases Age-Adjusted Death Rates
per 100,000 Population
Bucks
44.3
39.9
35.8
32.6
2010
Montgomery
HP 2020 Stroke Goal = 34.8
39.3
2011
39.1
2012
Pennsylvania Department of Health Epidemiologic Query and Mapping System
Recommendations included:
1) Raise awareness about disease prevention.
2) Raise awareness of "Know your Numbers" for individuals with pre-diabetes and type 2
diabetes who are more likely to have high blood cholesterol, high blood pressure, high
blood sugar, and be overweight/obese.
3) Need more ongoing education for adults with diabetes.
4) Promote healthy lifestyles
Maternal and Child Health
Data for natality is derived from the Pennsylvania and County Health Profiles, 2014, 2015
www.countyhealthrankings.org and Healthy People 2020.
The general fertility rate in Bucks and Montgomery counties is 49.3 and 59.0 per 1,000 women ages
15-44 respectively.
Birth Rates per 1,000 Women Age 15-44
85.1
74.7
68.7
59.0
49.3
58.1
48.4
38.1
36.1
3.0 18.2
3.7
Bucks
15-17
20.7
36.6
11.9
Montgomery
18-19
20-29
30+
Pennsylvania and County Health Profiles, 2014
54
PA
All Ages
The teen birth rate in Bucks and Montgomery Counties is less than half that of Pennsylvania as a
whole.
Teen (age 15-19) Births per 1,000 Female
Population
28
12
13
Bucks
Montgomery
PA
2015 Data, County Health Rankings.org
The Montgomery County Health Department (MCHD) condom distribution program mostly works
with colleges, businesses and community-based organizations. Typically, the school districts do not
obtain condoms from MCHD or allow the department to provide them at events in the school
environment. The school districts have periodically invited MCHD to conduct STD/HIV
presentations for the purpose of disease education without distribution of prevention tools.
Some teens may be gaining access to condoms either by visiting MCHD sites and/or via patient
interviews to STD positive individuals. If permitted, MCHD will mail condoms directly to the home
at no cost to the patient/student. Other organizations such as Planned Parenthood distribute condoms.
The Healthy People 2020 target rate infant and neonatal mortality is 6.0 and 4.1 infant deaths per
1,000 live births respectively. Infant mortality in Bucks and Montgomery counties is below the
Healthy People 2020 target. Infant mortality was higher among non-Hispanic blacks than nonHispanic whites; sample sizes for non-Hispanic Asians and Hispanics were too small.
Infant Mortality per 1,000 Live Births
Healthy People 2020 Target =6.0
5.3
5.2
Bucks
Montgomery
2015 Data, County Health Rankings.org
55
7.4
PA
Major reasons for infant deaths were pre-term birth and low birth weight.61 Babies weighing less
than 2,500 grams at the time of birth are considered to be low birth weight (LBW). Low birth weight
represents two factors: maternal exposure to health risks and an infant’s current and future morbidity,
as well as premature mortality risk. From the perspective of maternal health outcomes, LBW
indicates maternal exposure to health risks in all categories of health factors, including her health
behaviors, access to health care, the social and economic environment she inhabits, and
environmental risks to which she is exposed. In terms of the infant’s health outcomes, LBW serves as
a predictor of premature mortality and/or morbidity over the life course and for potential cognitive
development problems. One maternal health behavior that negatively affects infant health is
smoking. The percentage of pregnant women in Bucks and Montgomery counties who smoke is in
the lowest quintile in Pennsylvania.
In Bucks and Montgomery Counties, the percentage of low birth weight babies was below the HP
2020 goal. The highest rate of low birth weight babies in Bucks County was among black women,
with 11.9 % of babies with LBW, followed by Asian/Pacific Islanders at 10.8%. In Montgomery
County, the racial/ethnic group with the highest rate of low birth weight in 2012 was black women;
14.8% of their babies were of low birth weight, followed by 6.5 among whites and Hispanics of all
races.
56
%Low Birth Weight (<1500 grams) Babies
Healthy People 2020 Target =7.8
8.3
7.5
7.2
Bucks
Montgomery
PA
2015 Data, County Health Rankings.org
Preterm births are defined as births with less than 37 completed weeks of gestation. From 2010-2012,
9.3% and 8.1% of births in Bucks and Montgomery counties respectively were preterm. The Healthy
People 2020 target for preterm birth is less than 11.4% of births will be preterm.62 Montgomery
County is in the most favorable quartile for preterm births in the CDC CHSI comparison to peer
counties.
The Healthy People 2020 target for initiation of prenatal care in the first trimester is 77.9%. Overall,
Bucks and Montgomery counties exceed this goal, but there are significant racial/ethnic disparities.
In Bucks and Montgomery counties, the highest percentages of no prenatal care in the first trimester
in 2012 were among Hispanic women of any race (44.3 % and 49.2%) and among black women
(45.1% and 41.3%).
% with First Trimester Prenatal Care
78.2
78.5
Healthy People 2020
Target =77.9%
72.4
Bucks
Montgomery
PA
Pennsylvania and County Health Profiles, 2014
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to Maternal Child Health included:
57

Access to OB services
o "We have enough people and we have enough money, we need to figure out how to
spend our money and get rid of old barriers."
o Transportation issues impede access to care
o There are a lot of under-utilized services. "We have all the puzzle pieces, but it is hard
to put together."
o Better follow-up and referral, improved continuity

Mental and Physical Health
o Drug abuse, especially heroin, results in more babies being detained after birth
o Teen pregnancy is a concern
o Diabetes and obesity among pregnant women is an issue
Recommendations:
1) Each Women and Children's services division should have navigators to assist patients
with education, information and referral. Need to reeducate the frontline staff "to
change the old mindsets if we are going to be successful."
2) Obstetricians direct patients to prenatal classes.
3) Physicians and all health professionals need to learn all the services offered by the
organization.
Morbidity
Montgomery County ranks 6th and Bucks County 12th out of the 67 counties in Pennsylvania for
overall health outcomes. Ten percent of adults in Montgomery and 11% in Bucks County rate their
health as fair or poor compared to 14% in Pennsylvania and the Healthy People 2020 goal of 10%.
Adults in Montgomery and Bucks counties were less likely to report poor physical health days
(average number of physically unhealthy days reported in past 30 days - age-adjusted) than
Pennsylvania residents (2.9 days and 2.7 days vs. 3.5 respectively) and fewer poor mental health days
(average number of mentally unhealthy days reported in the past 30 days (3.1 days and 3.5 days vs.
3.6 days). The national benchmark for poor physical health days is 2.5 and 2.3 for poor mental health
days (County Health Rankings 2013).
Adults in Abington's CB area who report fair or poor health range from a low in Central Bucks
(6.5%) to a high in Indian Valley (16.7%). In contrast, almost 70% of adults in Upper Dublin rate
their health as excellent or very good.
58
Self Reported Health Status
100%
.
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Fair/Poor
10.6
16.7
13.8
6.5
12.3
9.8
9.6
13.5
Good
22.1
26.8
18.9
31.8
29.5
24.1
20.6
25.1
Excellent/Very Good
67.3
56.4
67.4
62.3
58.3
63.4
69.8
61.5
PHMC Household Health Survey 2015
Parents in North Penn/Indian Valley are more likely to rate their children's health as fair or poor than
Bucks/Mont (7.1% vs. 3.9%), while approximately only 1% of parents in William Tennent/Central
Bucks and Eastern Montgomery rate their children's health as fair or poor. Parents in Eastern
Montgomery are more likely to rate their children's health as excellent/very good than in Bucks/Mont
(note areas are consolidated due to sampling size)..
Childrens' Reported Health Status
100%
80%
60%
North Penn/
Indian Valley
William
Eastern
Tennent/
Montgomery
Central Bucks
Bucks/Mont
Fair/Poor
7.1
1.0
1.3
3.9
Good
7.0
12.2
6.8
7.9
Excellent/Very Good
85.9
86.8
92.0
88.2
PHMC Household Health Survey 2015
More education and identification of resources for chronic disease management was identified by key
informant interviews as an important community benefit issue:
59
Education regarding resources is lacking. Resources need to be out in the community and imbedded
in more practices or clinics.
Asthma
Asthma rates for adults in Abington CB areas are lower than Bucks/Montgomery rate. However, the
rates in all Abington CB areas exceed the rate in Pennsylvania (9.6%).63
% Ever Had Asthma
16.3
15.9
14.7
10.6
North Penn
Indian
Valley
William
Tennent
9.9
9.7
Central
Bucks
Lower
Eastern
12.0
11.5
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Children in the majority of Abington's CB areas are more likely to have asthma compared to
Bucks/Mont (15.2%) and Pennsylvania (13.7%).64 A key informant said that asthma rates among
youth have risen, and noted that pollution and lack of tree lined streets contribute to this increase.
The informant referred to a 2008 report in Journal of Epidemiology and Community Health that
found that children who lived on tree lined streets had lower rates of asthma and fewer
hospitalizations. Asthma is a major reason for absenteeism and truancy among school-aged children.
% Children Ever Had Asthma
17.4
16.7
15.2
11.2
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
PHMC Household Health Survey 2015
60
Bucks/Mont
Healthy People 2020 objectives for people with asthma focus on reducing asthma mortality, reducing
asthma hospitalizations and increasing the proportion of persons with asthma who receive formal
patient education.
Recommendations included:
1) Utilize the Asthma Link Line, a free community-based telephone center that integrates a
wide range of services for families of children with asthma. The program helps coordinate
medical appointments, asthma education and other services for families affected by
asthma. Child Asthma Link Line also helps uninsured families obtain health insurance.
Cardiovascular Disease, Stroke, and Diabetes
Heart disease, stroke and diabetes are among the top seven causes of mortality in Pennsylvania.65
Obesity and hypertension are underlying chronic diseases that increase risk of heart attack, stroke,
and complications of diabetes. The goal of Healthy People 2020 for heart disease and stroke is to
improve cardiovascular health and quality of life through prevention, detection and treatment of risk
factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; and
prevention of repeat cardiovascular events. Similarly, the Healthy People 2020 goal for diabetes is to
reduce the disease and economic burden and improve the quality of life for all persons who have, or
are at risk for, diabetes.
Diabetes
In Pennsylvania, the crude rate of adult diagnosed diabetes in 2013 was 10.1%.66 The percentage of
adults with diabetes has risen in Bucks and Montgomery counties since 2004 from 7.2% and 6.3% to
7.8% and 7.3% respectively in 2012.67 This represents approximately 88,000 adults who have been
told they have diabetes. Nationally, rates of diagnosed diabetes are higher among non-Hispanic
Blacks (13.2%), Hispanics (12.8%) and Asians (9.0%) than non-Hispanic whites (7.6%).68 New
federal statistics indicate that fewer cases of diabetes are being diagnosed in the United States: the
number of new cases dropped from 1.7 million in 2009 to 1.4 million in 2014.69 In Bucks/Mont,
11.2% of survey respondents report that they have been told they have diabetes. Diabetes rates are
highest in Lower Eastern and lowest in Central Bucks. The CDC's CHSI methodology ranks adult
diabetes morbidity in Montgomery County in the most favorable quartile compared to peer counties.
% Ever Had Diabetes
11.6
9.9
10.6
11.3
11.2
Abington
Upper
Dublin
Bucks/
Mont
7.2
7.1
3.0
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
PHMC Household Health Survey 2015
61
Compounding the higher rates of diabetes among blacks, African Americans in Southeastern
Pennsylvania are three times more likely than whites to have lower extremity amputations. Save
Your Soles is a grassroots program focused on eliminating this disparity. Working with community
churches and other groups, Save Your Soles teaches the importance of keeping blood sugar under
control, taking medications as prescribed, eating healthy foods, and getting regular exercise.
Abington podiatrist Dr. Ronald Renzi is publishing research about this topic.70
The increase in the prevalence of diabetes is a result of the obesity epidemic, the causes of which are
complex and include food insecurity, poverty, and decreased exercise. Only one third of adults in
Bucks/Mont who have diabetes say they exercise 3 or more times weekly compared to one half
without diabetes who do exercise regularly.
Diabetes education was identified as a priority by multiple key informants. At Abington Diabetes
Center, education is successful. In 2014, 28% of patients had an A1C level less than 7 (target value)
prior to entering the program. Post program, 67% of patients had an A1C level less than 7, a rate
better than the Healthy People 2020 goal of 58.9%. Other achievements are:
100% coping
98% achieved foot exam goal
94% medications
87% achieved at least a 1% decrease if their pre-program A1C was at least 8%
87% healthy eating
87% monitoring
72% risk reduction
71% exercise
68% complications
Healthy People 2020 objectives for people with diabetes include:
62




Increasing the proportion of persons at high risk for diabetes with pre-diabetes who report
trying to lose weight to 55%
Increasing the proportion of persons at high risk for diabetes with pre-diabetes who report
increasing their levels of physical activity to 49.1%
Increasing the proportion of persons with diabetes who receive formal diabetes education to
62.5%
Increasing the proportion of adults with diabetes who perform self-blood glucose monitoring
at least once daily to 70.4%
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to diabetes included:



Insurance/Cost
o Un or underinsured are not able to access care in a timely fashion
o The cost of insulin and co-pays/deductibles are barriers to care
o Resources for the uninsured and underinsured are lacking
Language barriers impede effective education and management in non-English speakers (key
informant, Korean community)
Knowledge
o Lifestyle education is needed
o Diabetes Center of AJH is resource
Recommendations included:
1)
2)
3)
4)
Expand care management into non-owned practices
Expand geriatric assessment to all chronic diseases
Focus on patients in the middle A1c area between 8-9
Work with Department of Nursing to expand diabetes education champions for
inpatients
5) Enhance diabetes education for the Korean community
6) Open ACLS and PALS training to the community
Hypertension
Hypertension rates in Pennsylvania (31.4%) are above the national rate for (28.7%) and well above
the Healthy People 2020 goal of 26.9%.71 Forty-one percent of those living below 200% FPL have
hypertension compared to 28% for wealthier people. Rates are highest among non-Latino blacks
(33.4%) and non-Latino whites (30.8%). Hypertension increases with age: almost 52% of all older
adults (aged 60+) in Bucks/Mont have or had hypertension (see older adult section). Several of
Abington's CB areas meet or exceed the Healthy People 2020 goal; however, rates in Indian Valley
and Lower Eastern are much higher.
63
% Doctor Ever Told have High BP
36.8
32.9
26.5
24.6
North Penn
Indian
Valley
William
Tennent
Healthy People 2020 Maximum
Target = 26.9%
30.1
28.5
26.3
21.2
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
The majority of Abington CB area residents with high blood pressure take medication; the percentage
in all regions exceeds the Healthy People 2020 goal of 69.5%.
% Currently Taking Medication for High Blood Pressure
80.0
North Penn
89.5
88.8
85.5
Indian
Valley
William
Tennent
Central
Bucks
Healthy People 2020 = 69.5%
92.5
85.6
79.3
Lower
Eastern
Abington
Upper
Dublin
85.1
Bucks/
Mont
PHMC Household Health Survey 2015
Of those taking medication for high blood pressure, most report taking the medication at least 90% of
the time. A higher proportion of people with hypertension in Central Bucks say they take the
medicine less than 90% of the time.
100%
80%
60%
40%
20%
0%
% Taking High BP Medications as Prescribed
North
Penn
Indian
Valley
William Central
Tennent Bucks
Less than 90% of the time
0.2
0.0
0.0
15.4
7.5
0.0
0.0
4.1
Nearly all of the time (90%)
6.2
14.0
6.7
6.2
1.2
3.0
16.3
5.9
All the time (100%)
93.6
86.0
93.3
78.4
91.4
97.0
83.7
89.9
PHMC Household Health Survey 2015
64
Lower
Upper
Abington
Eastern
Dublin
Bucks/
Mont
In numerous epidemiologic, clinical, and experimental studies, dietary sodium intake has been linked
to blood pressure, and a reduction in dietary salt intake has been documented to lower blood pressure.
In young people, blood pressure remains elevated even after a high salt intake is reduced. Older
adults, African Americans, and obese individuals are more sensitive to the blood pressure-lowering
effects of a decreased salt intake. High salt intake elevates risk of stroke and other conditions.72 In
Abington CB areas, those reporting watching or reducing their salt intake varies, with almost two
thirds in Indian Valley reporting they are at least aware of their salt intake compared to approximately
50% or less in the other areas.
% Currently Watching or Reducing Salt Intake
64.5
50.8
44.8
47.8
41.6
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
51.8
Abington
48.6
51.0
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
The definition of "too much salt" is left to respondent interpretation. Regardless, views on too
much salt vary across Abington CB areas. Eighty-four percent of residents of Indian Valley, the
Abington CB area with the second highest rate of high blood pressure (32.9%), think that too much
salt is very or somewhat harmful to health, compared to 62% in Abington, where 26.3% reported
hypertension.
% Who Think Too Much Salt is Harmful to Health
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
29.8
41.3
32.2
29.6
43.3
38.7
25.4
52.1
34.8
39.3
9.6
10.5
5.2
15.2
9.0
9.3
12.7
13.5
8.5
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
19.2
65
51.2
28.5
9.3
Lower Abington
Eastern
PHMC Household Health Survey 2015
29.0
Very harmful
36.9
46.3
24.0
22.5
2.3
Upper
Dublin
43.7
19.1
8.2
Bucks/
Mont
Somewhat
harmful
A little
harmful
Not at all
harmful
Across Bucks/Mont, more than one quarter of residents do not think too much salt affects risk of
stroke. In William Tennent, the percentage is more than one in three with this belief. Furthermore,
there appears to be a disconnect for some people between salt being harmful to health and salt
elevating risk of stroke. For example, 43.3% of residents in Central Bucks reported that salt is very
harmful to health, but only 37% thought the risk of stroke was significantly affected. In other areas,
the percentages were flipped, with higher percentages thinking too much salt affects that risk of
stroke than too much salt is harmful to health. These disparate responses suggest an opportunity for
education.
% Who Think Too Much Salt Affects Risk of Stroke
45.7
35.8
42.5
31.1
34.2
32.7
37.0
55.6
40.3
33.8
35.0
37.1
38.8
47.1
35.9
19.7
34.7
21.6
22.7
21.7
North Penn Indian Valley
William Central Bucks
Tennent
Not at all/ A little
24.6
27.4
Lower
Eastern
Some
Abington
27.0
17.9
Upper Dublin Bucks/ Mont
A lot
PHMC Household Health Survey 2015
Perhaps the 40% of William Tennent respondents who report always/often buying reduced salt
products affect the relatively low presence of high blood pressure (24.6%) in the community.
% Buying Items Labeled "Low Salt' or 'Low Sodium'
16.3
12.8
13.1
48.0
57.5
46.7
35.7
29.7
North Penn Indian Valley
23.1
51.2
40.3
25.8
14.6
18.5
51.3
34.2
16.6
43.4
15.9
45.6
38.1
38.6
36.4
47.0
William Central Bucks
Lower
Abington Upper Dublin Bucks/ Mont
Tennent
Eastern
Always/Often
Sometimes/Rarely
Never
PHMC Household Health Survey 2015
Although people may understand the link between high blood pressure and salt intake, they do not
always change their behaviors to benefit their health. For example, respondents in Central Bucks
reported the lowest level of high blood pressure (21.2%) and the highest percentage reporting that too
much salt is very harmful to health (43.3%), yet they are most likely to never buy products with
66
reduced salt (23.1%). The population in Central Bucks is younger, a factor contributing to the lower
prevalence of hypertension, but among those with high blood pressure, they are the least compliant
with taking blood pressure medicine. The complicated interactions between beliefs and behaviors
further supports the need to educate and halt the increase in stroke mortality recently experienced in
Bucks County and the comparatively higher stroke mortality in Montgomery County.
Healthy People 2020 objectives related to hypertension include:
 Reduce the proportion of adults with hypertension to 26.9%
 Increase the proportion of adults aged 20 and older who are aware of the early warning
symptoms and signs of a heart attack to 59.3%
 Increase the proportion of adults who have had their blood pressure measured within the past
two years and can state whether their blood pressure is high or normal to 92.6%
 Increase the proportion of adults with hypertension who are taking the prescribed medications
to lower their blood pressure to 69.5%
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to cardiovascular disease included:


Awareness
o Need cardiac education including information on healthy lifestyles and low sodium diets
o The Korean community needs education on hypertension; language is a barrier
o Cardiac disease in women needs attention, as does peripheral artery disease
Access to healthy (low sodium) is more costly
Recommendations included:
1)
2)
3)
4)
5)
6)
7)
Raise awareness about signs and symptoms of heart attack and stroke
Increase access to chronic disease management programs
Work with the Korean community to improve prevention, education, and care
AJH could provide free programming, health fairs, blood pressure screenings
Increase community education and involvement in support groups and the Heart Walk.
Children's education - focus on hands only CPR
Use different approaches for different people: Better messaging needed for "Know Your
Numbers"
67
Obesity and Nutrition Education
In the United States, almost 35% of adults are obese, and in Pennsylvania, the self reported obesity
rate in 2014 was 30.2%.73 Diet and body weight have been shown to be related to overweight/
obesity, malnutrition, iron deficiency anemia, heart disease, high blood pressure, dyslipidemia, Type
2 diabetes, osteoporosis, asthma, and some cancers. Increases in obesity related diseases are
projected to be significant.74
Obesity Related Diseases in Pennsylvania
Heart disease
Obesity related cancers
Diabetes
Hypertension
2010 Cases
2030 Projection
%Change
892,129
227,588
3,964,312
553,041
344%
143%
1,135,646
2,752,209
1,731,248
3,483,650
52%
27%
The obesity rate in all Abington CB areas is below the Healthy People 2020 goal of 30.5%. The rate
of overweight adults ranges from 24.8% in Central Bucks to 41.7% in William Tennent. People in
Bucks/Mont with incomes above 200% FPL are less likely to be obese compared to those below this
level (26.8% vs. 32.8%). Disparities in obesity exist with Latinos most likely to be obese compared
to non-Latino whites, blacks, and Asians (32.6%, 28.3%, 28.6%, and 6.4% respectively). Overall,
more than 318,000 adults in Bucks/Mont are obese and 398,000 are overweight.
70
60
50
40
30
%
20
10
0
Obesity Level: %
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Abington
Eastern
Upper
Dublin
Bucks/
Mont
Overweight
39.7
37.4
41.7
24.8
38.0
35.2
27.7
34.8
Obese
26.0
26.2
23.1
27.3
HP 2020 Target
28.0
28.2
23.7
27.8
30.5
30.5
30.5
30.5
30.5
30.5
30.5
30.5
PHMC Household Health Survey 2015
Obesity rates for youth in Abington CB areas are slightly above the Healthy People goal of less than
14.5%, with the highest rate reported in Eastern Montgomery (16.5%). In addition, between 9 and
16% of children in Abington's CB areas are overweight.
68
Child BMI for Age Percentile Category
100%
80%
60%
40%
20%
0%
North Penn/ William Tennent/
Eastern
Bucks/Mont
Indian Valley
Central Bucks
Montgomery
obese: 95-110 %ile
overweight: 85-94 %ile
Normal: 5-84 %ile
Underweight: 0-4 %ile
Healthy People 2020 Target: < 14.5% obese children and adolescents
PHMC Household Health Survey 2015
Breastfeeding has been shown to be associated with lower obesity rates in children. For the period
2010 - 2012, 77.4% of mothers in Bucks County and 85.8% in Montgomery County reported
breastfeeding their infants, compared to 71.3% in Pennsylvania. The Healthy People 2020
breastfeeding goal is 81.9%.75 In the Spring of 2015, Abington was selected to be among the first
hospitals in the nation to join the EMPower Initiative to enhance maternity care practices including
breastfeeding and work toward achieving the Baby-Friendly USA© designation.76
The Healthy People 2020 objectives related to obesity and nutrition education include:





Increase the proportion of worksites that offer nutrition or weight management classes or
counseling
Increase the proportion of adults who are at a healthy weight to 33.9%
Reduce the proportion of adults who are obese to 30.5%
Reduce the proportion of children and adolescents who are considered obese to 14.5%
Increase the proportion of physician office visits made by adult patients who are obese that
include counseling or education related to weight reduction, nutrition or physical activity to
31.8%
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to obesity included:
o Increase awareness
o There are a lack of resources for obesity
o Co-morbidities are related to BMI
o Obesity among pregnant women, African Americans, and other minorities
o Increase physical activity
o Sedentary lifestyles are problematic
69
o People need to take time out of their day for physical activity. Exercise or walk at
work
o Example: funding through the Abington School District for health/physical education
staff goes a long way toward addressing child and teen obesity
o Promote lifestyle coach programs and train more coaches
o Employers are providing time, support and expertise at workplace for exercise and
stress reduction
o Improve access to healthy, affordable food
o The need for affordable healthy grocers/markets was identified
o Raise community awareness that eating well is more costly
o More publicity of AJH's nutrition center
o Improve access to weight management programs
o People are accessing their insurance for weight management/visits; more education is
needed with an emphasis on lifestyle behaviors
o Some medications cause weight gain
Mental Health
Mental and physical healthcare are inter-related. Mental health plays a major role in people’s ability
to maintain good physical health. However, mental illness, such as depression and anxiety, can limit
the ability to integrate health-promoting behaviors into one’s life. Conversely, physical health issues,
such as chronic disease, can have a serious impact on mental health and may inhibit full participation
in treatment and recovery.
Just under 15% of all adults in Bucks/Mont have been diagnosed with a mental health condition.
People living below 200% FPL are much more likely to have a mental health condition (22.9%)
compared to those who live above 200% of the federal poverty level (13.2%). Diagnosed mental
health conditions vary greatly by race/ethnicity, perhaps due to cultural perceptions regarding
recognition and acceptance of mental disorders. Non-Latino whites were most often diagnosed
(15.6%), compared to 12.9% of non-Latino blacks, 11.3% of Latinos, and 4.9% of non-Latino Asians.
Residents living in Central Bucks and Lower Eastern report the highest rates with nearly 21%
diagnosed with a mental health condition, while in Abington 6.1% report such conditions.
%With Diagnosed Mental Health Condition
16.9
18.9
20.7
20.6
14.9
11.0
9.8
6.1
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
PHMC Household Health Survey 2015
70
Abington
Upper
Dublin
Bucks/ Mont
Almost four in ten of those with a mental health diagnosis in Bucks/Mont report they are not
receiving treatment for their condition. Among Abington's CB areas, the percentage not receiving
treatment varies greatly, with more than half not receiving treatment in North Penn and Lower
Eastern. The low rate of diagnosed mental health conditions in Abington, coupled with a nontreatment rate near 50%, suggests an opportunity to diagnose and treat people needing care.
% Not Currently Receiving Treatment for a Mental Health Condition
54.0
51.5
46.5
37.6
32.2
25.6
16.8
11.3
North Penn Indian Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/ Mont
PHMC Household Health Survey 2015
Mental Health issues for Older Adults are discussed in the Special Population section.
Healthy People 2020 objectives related to mental health include:

Increase the proportion of primary care facilities that provide mental health treatment onsite or
by paid referral to 87%
 Increase the proportion of adults with serious mental disorders who receive treatment to
72.3%
 Increase the proportion of adults aged 18 years and older with major depressive episodes
(MDEs) who receive treatment to 75.9%
 Increase the proportion of primary care physicians who screen adults aged 19 years and older
for depression during office visits to 2.4%
 Reduce the suicide rate to the Healthy People goal of 10.2 per 100,000 population. The
Pennsylvania rate for 2015 was 13.6,77 Bucks was 11.4 and Montgomery was 10.1 and
rising.78
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to mental health included:


Training
o Mental health diagnoses in the community, including among pregnant women, are often
missed
Cultural issues
o " There is still a stigma about seeking help"
o Jaisohn is spending more resources and manpower for the Korean community but it is not
enough
71


Access
o Shortage of affordable and available psychologists and counselors
Stress and work life balance
o Constant job worries, more hours expected, more pressures. Mental health issues relate to
other conditions including obesity issue and diabetic crisis.
HIV Status
The prevalence rate of HIV in Bucks and Montgomery counties is 133 and 140 per 100,000
population, compared to 292 for Pennsylvania (as reported by countyhealthrankings.org). This
equates to 1,637 individuals living with diagnosed HIV in Bucks/Mont. According to the CDC
CHSI, AIDS morbidity in Montgomery County is in the most favorable quartile compared to peer
counties. In Southeastern Pennsylvania, 71% of people living with HIV at the end of 2014 were
male. Sixty percent of these people were Black compared to 23% White and 13% Hispanic.
According to Pennsylvania statewide data for 2001-2014, the most common mode of transmission is
heterosexual transmission (38%) followed by men who have sex with men (MSM) (35%), and
injection drug use (IDU) (16%). HIV is much more likely to be transmitted by MSM among Whites
compared to Blacks (52% vs. 29%) and among Blacks, heterosexual transmission is twice as common
compared to Whites (46% vs. 23%).79
According to PHMC Household Health Survey 2015 data, residents living in the majority of
Abington CB areas are less likely to have been tested for HIV than in Pennsylvania statewide (37%
ages 18-64 were tested)80; all testing rates are well below the Healthy People 2020 goal. Testing rates
exceed the state rate only in Lower Eastern and Upper Dublin.
Montgomery County's Health Department HIV/STD program offers free confidential testing for
sexually transmitted infections including the OraQuick Advance Method for rapid HIV testing at its
clinics and provides condoms and prevention materials at its clinics and by mail to Montgomery
County residents.81 Bucks County Department of Health also offers free confidential or anonymous
HIV testing.
% Ever Tested for HIV
Healthy People 2020 Target = 73.6%
32.3
37.7
North Penn Indian Valley
45.3
27.7
27.3
William
Tennent
Central
Bucks
40.6
37.9
25.2
Lower
Eastern
PHMC Household Health Survey 2015
72
Abington Upper Dublin Bucks/ Mont
Hospital Readmissions
The Centers for Medicare & Medicaid Services (CMS) defines readmission as an admission to a
hospital within 30 days of a discharge from the same or another hospital. Readmissions are prevalent
and expensive. Avoidable complications and readmissions due to inadequate care coordination and
poor management of care transitions were responsible for $25 to $45 billion in wasteful spending in
2011. As of October 2012, the Affordable Care Act requires CMS to decrease Medicare payments to
hospitals for excess readmissions, providing the policy lever that induces hospitals to act quickly to
reduce readmissions. Thousands of hospitals have already faced penalties for high readmissions for
pneumonia, heart failure and heart attack.
Nationally, and in Pennsylvania, the re-hospitalization rate among Medicare beneficiaries within 30
days is 20%, and 50% of the patients readmitted within 30 days were not seen by an outpatient
provider prior to readmission.82 These re-hospitalizations are costly and, for the most part,
preventable through timely and effective outpatient care and adequate patient disease selfmanagement practices. The Pennsylvania Health Care Cost Containment Council published a report
on re-admissions within 30 days for adult patients who were discharged January 2013 through August
2014 and were initially admitted with any of these 4 conditions: abnormal heartbeat; chronic
obstructive pulmonary disease (COPD); congestive heart failure (CHF); and medical management of
diabetes. Abington Hospital's 30 day same condition readmission rates were not statistically different
than expected for each of these conditions, and readmission rates for residents of Montgomery
County were close to the state average for 3 of the four conditions. Montgomery County residents
fared better than the state average in terms of readmissions for medical management of diabetes, and
Bucks County residents had better than average readmission rates for CHF and diabetes medical
management.83
30 Day % Readmitted for Same Condition
Abnormal heartbeat
COPD
CHF
Diabetes Medical Management
PA
3.6
7.7
7.7
8.4
Bucks
3.7
7.9
6.5
6.1
Montgomery
3.7
7.9
7.5
7.6
In FY 2015, the 30 day overall readmission rate at Abington was 10%. As previously stated, health
literacy is one factor related to readmission to the hospital within 30 days of discharge.
73
Abington Overall 30 Day Readmission
Rate
10.69%
10.03%
9.71%
FY 2013
FY 2014
FY 2015
Abington internal data
AJH's 3R's program, Reducing Readmissions Remotely, shows promise for reducing readmissions.
AJH developed preferred relationships with 6 local skilled nursing facilities (SNF) with the goal of
reducing costs while maintaining and improving the quality of care for stroke, heart failure, acute
myocardial infarction, chronic obstructive pulmonary disease, coronary artery bypass graft,
pneumonia, and orthopedic patients. Remote pharmacists reconcile medication discrepancies for
omissions, wrong medication strength, dose, and frequency during transitions of care from the acute
hospital to the SNF. Although a statistical analysis was not performed, the readmission rate at the
end of the initial period had decreased.
While most patients could benefit from improved discharge planning and care coordination and
management, non-English speaking patients, homeless/sheltered patients, the elderly and those with
both mental illness and chronic diseases may be most likely to benefit.
An important subset of readmissions due to chronic illness affects a particularly vulnerable
population struggling with complex medical and psychosocial challenges and may be addressed by
improved discharge planning, care coordination, and care management. Care coordination and care
management can include components such as patient navigators, care or case managers, community
health workers, nurses, social workers, and coaches for target patient groups. Models include design
of individualized plans with and for patients in the context of the patients’ assets (social support,
existing relationships with providers, etc.). These plans must be dynamic, and the process of care
coordination includes feedback loops to respond in an ongoing way to the changing needs of the
patient. Coordination can be performed by a person or team with three primary responsibilities: value
proposition, service design, and service delivery, requiring skill sets of social workers, nurses, and
community health workers, depending on the primary needs of the individual patient.
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to hospital readmissions included:

Post acute system of care has not kept pace with need
 Need more home visits post discharge
74
Preventive Care and Early Detection of Disease
People who have a regular health care provider are more likely to have better health outcomes.
Having a regular source of care can help to reduce health disparities and costs and increase preventive
health screenings. This is key to detecting signs/symptoms that are precursors to disease and to
detecting disease earlier when it is often more treatable.
With the exception of Central Bucks, residents in Abington CB areas and Bucks/Mont do not meet
the Healthy People 2020 target for having a specific source of ongoing care.
% With Regular Source of Care
97.1
92.4
88.9
90.9
88.8
88.2
88.7
81.2
North Penn Indian Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington Upper Dublin Bucks/ Mont
Healthy People 2020 Target for a specific source of ongoing care= 95%
PHMC Household Health Survey 2015
The majority of residents receive their care in a private physician's office. Indian Valley residents
receive their regular care somewhat differently than residents in other Abington CB areas: 87.6% are
seen in a private doctor's office, 7.2% in a hospital clinic, and 4.6% in a community health center or
public clinic.
Regular Source of Care
Other place
100%
95%
90%
85%
80%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
PHMC Household Health Survey 2015
75
Abington
Upper
Dublin
Bucks/
Mont
Hospital
emergency
room
Hospital
outpatient
clinic
Community
Health Center
or public clinic
Private doctor's
office
The majority of residents in Abington CB areas have visited a health care provider at least once in the
past year. However, approximately 1 in 7 who live in North Penn, Indian Valley, or Abington did not
visit a health care provider during the past year. Lack of physician counseling and referral is known
to negatively impact preventive screen rates. More Lower Eastern residents (63.7%) visited providers
at least 3 times over the last year.
# of Visits to Health Care Provider in Past Year
100%
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
3 or more
36.6
34.3
41.3
46.8
63.7
34.5
41.7
43.9
1 to 2
49.2
50.1
48.5
42.5
27.0
49.5
52.0
42.8
No visits
14.3
15.5
10.1
10.8
9.3
16.0
6.3
13.3
PHMC Household Health Survey 2015
Almost all children in Abington's CB areas have a regular source of care and nearly meet the Healthy
People 2020 goal of 100% children age 0-17 have a specific source of ongoing care.
% Children With Regular Source of Care
Healthy People 2020 Target for a specfic source of ongoing care =
100% for children aged 0-17
97.7
96.2
96.1
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
96.6
Bucks/Mont
PHMC Household Health Survey 2015
Approximately 96% of children in Abington's CB areas receive care at private doctor's offices.
76
Childrens' Source of Care
100%
98%
96%
94%
92%
90%
North Penn/ Indian William Tennent/
Eastern
Bucks/Mont
Valley
Central Bucks
Montgomery
Other place
Hospital emergency room
Hospital outpatient clinic
Community health center or public clinic
Private Doctor's Office
PHMC Household Health Survey 2015
Residents in North Penn and Abington reported the lowest use of emergency departments. People
living in these areas also visited their regular source of care less often than residents of most other
regions.
# of Visits to ER in Last Year
100%
80%
60%
40%
20%
0%
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
2 or more
7.2
11.4
6.0
4.6
11.3
4.5
6.2
8.9
1
13.6
13.2
20.4
20.3
17.9
14.9
15.9
16.2
0
79.2
75.3
73.6
75.2
70.8
80.6
77.9
74.9
PHMC Household Health Survey 2015
According to FY 2015 data for Abington Hospital, there were 97,447 emergency room visits.
Overall, 30% of these visits were rated a 4 or 5 on the ESI acuity scale that is used in the emergency
department.84 Acuity scores of 4 or 5 are considered non-emergent or ambulatory care sensitive
conditions and preventable through primary care. Fifty eight percent of all emergency care visits with
an acuity scale of 4 or 5 were from Abington's primary service area. The majority of these visits were
for complaints related to ankle, leg, shoulder joint pain (16%), limb swelling and other soft tissue
disorders (14%), general symptoms related to open wounds (9%), general symptoms related to the
head and neck (headaches, sore throat, jaw pain, etc.) (7%), back disorders (7%), skin disorders
(rashes, swelling, etc.) (5%), and respiratory symptoms (5%). These chief complaints account for
77
63% of all ED visits with acuity scores of 4 or 5. The majority of ED visits for conditions with acuity
scores of 4 or 5 were among 18 to 44 year olds (39%) and patients under age 18 (30%).
Lack of health insurance and low socio-economic status are factors most related to disparities in
cancer incidence and death. The Healthy People 2020 objectives for cancer reflect the importance of
promoting evidence-based screening for cervical (PAP), breast cancer (mammography), and
colorectal (fecal occult blood testing, sigmoidoscopy, or colonoscopy). These objectives are to:



Increase the proportion of women aged 21-65 who receive a cervical cancer screening based
on the most recent guidelines to 93%
Increase the proportion of women aged 50-74 who receive a breast cancer screening based on
the most recent guidelines to 81.1%
Increase the proportion of adults aged 50-75 who receive a colorectal cancer screening based
on the most recent guidelines to 70.5%
The percentage of women in Bucks/Mont and in Abington's CB area who were screened for cervical
cancer with a PAP test in the past 3 years was well below the Healthy People 2020 goal of 93%.
According to the CDC CHSI methodology, Bucks County ranks in the least favorable quartile
compared to peer counties for PAP tests. Women living in Indian Valley were least likely to have
been screened for cervical cancer and women in North Penn and William Tennent were most likely to
have been screened (84.1% and 82.6% respectively). Non-Latina blacks report the highest rate of
PAP test in the past 3 years (89.8%), followed by Latinas (85.6%), non-Latina Asians (79.3%) and
non-Latina whites (75.3%). Efforts to reach non-Latina blacks are most successful and need to be
expanded to women of other races and ethnicity.
% Having Pap Test within 3 Years
Healthy People 2020 Target = 93%
84.1
82.6
78.9
81.0
William
Tennent
Central
Bucks
Lower
Eastern
71.4
North Penn Indian Valley
75.1
80.2
76.3
Abington Upper Dublin Bucks/ Mont
PHMC Household Health Survey 2015
Breast cancer is the second most common type of cancer (skin cancer is more common) for women in
the United States85 and in Pennsylvania and Montgomery County, accounts for the second highest
number of cancer deaths behind lung cancer.86,87
Compared to women in Bucks/Mont, women in Abington's CB communities were more likely to have
had a breast exam in the past year, with the exception of North Penn females. However, the majority
(87%) of North Penn residents report having a mammogram within the past 2 years.
78
% No Breast Exam by Health Care Professional Within the Past Year
38.7
33.1
32.6
32.1
33.1
32.4
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
28.4
North Penn
Indian
Valley
35.0
Bucks/
Mont
PHMC Household Health Survey 2015
The Healthy People 2020 goal for women aged 50-74 who had a mammogram based on the most
recent guidelines is 81.1%. Five of the seven Abington CB areas are close to or exceed this goal.
Women in Abington and Indian Valley had lowest mammography rates (73.6% and 75.1%
respectively). Fewer women living below 200% federal poverty level had mammography screening
within the past two years (56.5%) than non-poor women (81.5%). Interestingly, white non-Latina
women were less likely to have had a mammogram in the past two years (75.3%) compared to nonLatina black women (98.4%) and Latinas (84.9%). Non-Latina Asian women were least likely to
have had a mammogram in the past two years (72.9%). This speaks well for breast screening efforts
to reach some minority women, but highlights a need to ensure white and Asian women also reach
the screening goals.
Time Since Last Mammogram
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
12.9
17.8
69.3
North Penn
24.9
21.9
16.4
19.3
58.7
58.8
Indian
Valley
William
Tennent
one year or less
8.9
18.0
8.9
69.8
73.1
Central
Bucks
Lower
Eastern
21.3
11.8
26.4
19.3
16.6
57.0
Abington
> 1 year, up to 2 years
23.1
15.4
68.8
61.5
Upper
Dublin
Bucks/
Mont
> 2 years
Healthy People 2020 Goal = increase % of women aged 50-74 years who had a mammogram
based on the most recent guidelines to 81.1%
PHMC Household Health Survey 2015
79
Although the breast and cervical cancer burden index for Bucks and Montgomery counties is
elevated, Bucks County has no Healthy Women Program providers.88 Abington participates in
Pennsylvania’s Healthy Woman Program for breast screening services and can treat patients enrolled
in Pennsylvania’s Breast Cancer and Cervical Cancer Prevention and Treatment Program. These
programs assist un- and underinsured women with low incomes to obtain cervical and breast cancer
screening and assist women in getting treatment if they are diagnosed with cancer.
The Healthy People 2020 target for colon cancer screening is for 70.5% of people aged 50-75 to meet
the most recent screening guidelines. Twenty two percent of adults aged 60+ in Bucks/Mont have
never had or not had a colonoscopy/sigmoidoscopy in more than 10 years. North Penn/Indian Valley
residents are least likely to have had this screening, while the vast majority of adults age 60+ in other
Abington CB areas report having timely colon cancer screenings. Bucks/Mont residents living below
200% FPL were more likely not to have had colon cancer screening in more than 10 years compared
to those living above this level of poverty (36.8% vs. 18.7%). Only 6.7% of non-Latino blacks say
they have not had a colonscopy/ sigmoidoscopy in the past 10 years. Non-Latino whites (23.3%),
non-Latino Asians (29.8%), and Latinos (38.2%) report higher rates of never had or greater than 10
years since last colonscopy/sigmoidoscopy.
80
% Age 60+ Never Had or > 10 Years Since
Last Sigmoidoscopy/Colonscopy
24.7
22.3
5.5
2.2
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to preventive health screening included:

Cancer
o Although most are insured, the cost of cancer care including medications and co-pays
creates financial stress and the need for financial assistance
o Many cancer patients need assistance at home, including child care for dependent children,
in-home care for seniors living alone, and family support
o Special diet and diet teaching is lacking
o Substance abuse can be rampant due to lack of hope
o Denial of outcomes by both patients and physicians lead to underuse of hospice
o Need to raise awareness about the cultural and language barriers that impede compliance
with protocols and some aspects of care
o Cancer prevention, education, and insurance issues are a concern in the Korean
community
Recommendations included:
1) More options for affordable in home personal assistance
2) Availability of and access to dietitians
3) Education and sufficient, competent interpreters for patients with cultural and language
barriers
4) Better education for providers, patients, and families to prepare for end of life
Dental Care
More than one quarter (27%) of Bucks/Mont residents did not see a dentist in the past year. Between
6 and 18% have not seen a dentist in more than 2 years. People living below 200% of the poverty
level were less likely to have seen a dentist in the past year (51.7%) compared to those above this
81
poverty level (76.6%) and non-Latino blacks, non-Latino Asians, and Latinos were more likely than
non-Latino whites to not have seen a dentist (29.6%, 38.5%, 27.4% and 26.8% respectively).
Time Since Last Dentist Visit
100%
80%
60%
40%
20%
0%
North Penn
Indian
William
Valley
Tennent
one year or less
Central
Lower
Abington
Bucks
Eastern
> 1 year, up to 2 years
Upper
Dublin
> 2 years
Bucks/
Mont
Healthy People 2020 Goal - increase the proportion of children and adults who use the oral
health care system each year by 10%
PHMC Household Health Survey 2015
Children were more likely to have seen a dentist in the past year than adults, although approximately
1 in 7 in Bucks/Mont did not. Children living in the Abington communities were least likely to have
had a dental visit in the past year.
% Children without a Dental Examination in the Past Year
17.0
13.7
15.3
9.6
North Penn/ Indian
William Tennent/ Eastern Montgomery
Bucks/Mont
Valley
Central Bucks
Healthy People 2020 Goal - increase the proportion of children and adults who use the
oral health care system each year by 10%
PHMC Household Health Survey 2015
Although children in William Tennent/Central Bucks were most likely to have a dental exam within
the past year, they are more likely to report that cost is a barrier to receiving dental care.
82
%Children Not Receiving Dental Care due to Cost
7.3
4.7
4.2
2.8
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
AJH supports two dental clinics. Comprehensive dental services are provided by resident dentists
with oversight from attending dentists on the Abington Hospital campus. The AJH Dental Care
Access Program is designed to provide basic dental services to underinsured and uninsured residents
of the greater North Penn community through a network of participating local dentist members of the
Montgomery-Bucks Dental Society. Information about these services is available in English,
Spanish, and Korean.
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to dental care included:




Abington Hospital and CHOP offer advanced dental care for children; transportation is an
issue for some.
There is a lack of affordable advanced dental care
There are not enough dentists registered in the Greater North Penn communities for the dental
access program
Community members are in need of more extensive dental work. Volume exceeds capacity.
83
Health Behaviors
The figure below depicts the leading reported causes and actual causes of death in the United States at
the turn of the century - tobacco, poor diet and lack of physical activity, and alcohol. Counseling for
these health behaviors and policy changes to create a healthier environment and improved access to
healthy affordable food are keys to improving health in the United States and Bucks/Mont.
Community-level initiatives such as tobacco-free restaurants and campuses, pedestrian-friendly cities,
and increasing access to nutritious food sources play a critical role in changing health-related
behaviors.
The following describes the current health behaviors of adults and youth in Abington CB areas and
Bucks/Mont.
Smoking
Tobacco use is the single most preventable cause of death and disease in the United States. Tobacco
use costs the U.S. $300 billion annually in direct medical expenses and lost productivity.89 Close to
13% of Bucks/Mont residents smoke – a percentage just above the Healthy People 2020 target of
12%. Nearly 22% of those living below 200% FPL smoke compared to 11% of those living above
200% FPL. In Bucks/Mont, smoking rates are higher among non-Latino blacks (12.7%) and nonLatino whites (13.4%) than Hispanics (9.6%). Adults living in Central Bucks are slightly more likely
to smoke (12.8%) than Bucks/Mont residents. Adult smoking in Montgomery County is rated in the
least favorable quartile by the CDC CHSI methodology when compared to peer counties.
84
% Who Smoke
Healthy People 2020 Target = 12%
12.8
12.0
11.5
9.2
7.1
9.0
7.5
North Penn Indian Valley
William
Tennent
12.6
Central Bucks
Lower
Eastern
Abington Upper Dublin Bucks/ Mont
PHMC Household Health Survey 2015
Fifty-five percent of smokers in Bucks/Mont attempted to quit smoking in the past year, a rate much
lower than the Healthy People 2020 target. Fewer than half the smokers in Lower Eastern, Indian
Valley, and North Penn tried to quit smoking and more than three quarters in William Tennent
attempted quitting.
% WhoTried to Quit Smoking in Past Year
Healthy People 2020 Target = 80%
76.9
65.2
48.7
64.9
40.8
North Penn Indian Valley
60.3
55.1
35.6
William
Tennent
Central Bucks
Lower
Eastern
Abington Upper Dublin Bucks/ Mont
PHMC Household Health Survey 2015
Methods used to try to quit smoking vary across Abington CB areas. Counseling was mentioned by a
minority of smokers. Free smoking cessation resources are available at the state (PA QUIT Line and
FAX to QUIT programs). Abington Hospital is a member of the Coalition for a Tobacco-Free
Montgomery County, a group of concerned individuals from businesses, organizations, health care
and public health groups and the community working to reduce tobacco use and exposure to tobacco
smoke pollution. The Bucks County Health Improvement Partnership (BCHIP) coordinates free
smoking cessation programs on a rotating basis at many locations throughout Bucks County including
the six hospitals, parks and recreation departments, and local churches.
85
Newer JCAHO standards require identifying smoking status of patients and helping them develop a
plan to quit.
Methods Used to Try to Quit Smoking
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other
Chantix or Zyban
E-cigarette
Counseling
North
Penn
Indian William Central Lower Abington Upper
Valley Tennent Bucks Eastern
Dublin
Bucks/
Mont
Nicotine replacement
witih/wo other method
On own without
assistance
PHMC Household Health Survey 2015
Fewer than 8% of Bucks/Mont residents report smoking e-cigarettes, and less than 2% smoke ecigarettes daily.
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
% Smoking e-cigarettes/Frequency of Use in the Past Month
North Penn Indian Valley
William
Tennent
Once/ a few times
Central Bucks
Lower
Abington Upper Dublin Bucks/ Mont
Eastern
At least once per week
Daily
PHMC Household Health Survey 2015
Healthy People 2020 objectives related to smoking cessation include:





Reduce cigarette smoking by adults to 12%
Increase smoking cessation attempts by adults to 80%
Increase recent smoking cessation success by adult smokers to 8% and adolescent smokers to
64%
Increase tobacco screening in office-based ambulatory care setting to 68.6%
Increase tobacco screening in hospital ambulatory care setting to 66.2%
86


Increase tobacco cessation counseling in office based ambulatory care settings to 21.1%
Increase tobacco cessation counseling in hospital ambulatory care settings to 24.9%
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to preventive health screening included:



Teen smoking and smoking among the African American and other minority populations is a
concern
Those with mental health issues may not know or be aware smoking cessation assistance
Resources for smoking cessation are a barrier
Physical Activity
Regular physical activity is important to reducing overweight and obesity rates and has been shown to
lower adults’ risk of early death, coronary heart disease, stroke, high blood pressure, Type 2 diabetes,
breast and colon cancer, falls, and depression. Among youth and adolescents, regular physical
activity improves bone health, improves cardiorespiratory and muscular fitness, decreases body fat
levels, and helps to reduce symptoms of depression. Even small increases in physical activity have
been associated with benefits to health. People who are more physically active are more likely to
have higher education levels, income, self-efficacy, support from others, access to
exercise/recreational facilities they find to be satisfactory, and live in neighborhoods that are
perceived to be safe. Advancing age, low income, lack of time, lack of motivation, perception of
poor health, overweight/obesity and being disabled negatively impact physical activity. Healthy
People 2020 supports a multi-disciplined approach to addressing physical inactivity. These
approaches include expanding traditional partnerships (schools, health care, recreational
organizations such as the YMCA and biking coalitions) to include non-traditional partners such as
transportation, zoning, streets departments (sidewalks, street crossings), parks and recreation
departments, and city planning. Policies that promote physical activity in schools, workplaces and
childcare as well as improvements to the environment that support physical activity are needed
(Healthy People 2020). Healthy People 2020 includes the following objectives:






Increase the proportion of adults who participate in moderate aerobic physical activity for 150
minutes per week to 47.9%
Increase the proportion of adolescents who meet the current federal guidelines for physical
aerobic activity to 31.6%
Increase the proportion of public and private schools that require daily physical education in
elementary schools to 4.2%; in middle schools to 8.6%; and high schools to 2.3%
Increase the proportion of adolescents who participate in daily school physical education to
36.6%
Increase the proportion of school districts that require regularly scheduled elementary school
recess to 62.8%
Increase the proportion of youth/adolescents who view television, videos or play video games
for no more than 2 hours daily. The target for children age 2-5 is no more than 83.2%; for
ages 6-14 to no more than 86.8%; and the proportion of adolescents in grades 9-12 to no more
than 73.9%.
87




Increase the number of states with licensing regulations for physical activity provided in
child care
Increase the proportion of the nation’s public and private schools that provide access to their
physical activity spaces and facilities for all persons outside of normal school hours (that is,
before and after the school day, on weekends, and during summer and other vacations) to
31.7%
Increase the proportion of physician office visits that include counseling or education related
to physical activity for children and adults to 8.7%
Increase legislative policies for the built environment that enhance access to and availability
of physical activity opportunities
In Bucks/Mont, 51.2% of adults do not get the recommended daily amount of physical activity.
Adults in Lower Eastern are least likely to exercise regularly (3 or more times weekly for at least 30
minutes) and residents of North Penn are most likely to meet this goal (80.5%). Twenty two percent
of Bucks/Mont adults say they exercise less than once per week. More than 25% of adults in
WilliamTennent are physically active less than once weekly, compared to 16.8% in Indian Valley.
% Exercising > 30 Minutes: # Days/Week
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
=>3
days/week
1-2
days/week
< once/week
None
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Reported exercise patterns do not correspond to the proportion of adults who are comfortable visiting
an outdoor space or park during the day. Residents of William Tennent, who report being the least
active, also are the most comfortable being in an outdoor space or park during the day. Frequency of
exercise does not appear to be directly related to availability of safe outdoor areas.
88
% Comfortable Visiting a Nearby Park or Outdoor Space
During the Day
88.7
85.8
84.8
86.8
88.5
82.4
82.1
74.0
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Regardless, Montgomery County has been strategically working to improve the environment to
increase opportunities for safe places for physical activity (See the Social Determinants section on the
Built Environment).
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to being physically active included:




The morbidity section on obesity also provides key informant and focus group comments
about physical activity
Too much work at computers leads to a sedentary lifestyle
Need safe walking environment
Need more municipal sports programs
Recommendations included:
1) Promote bike share programs and walkable communities
2) More school and community physical activity opportunities for youth and older adults
Healthy and Affordable Food
As mentioned previously, obesity is a major cause for concern both nationally and in Bucks and
Montgomery counties (see Morbidity section on Obesity). Interventions to address a healthier diet
should include improving nutrition knowledge, attitudes, and skills of individuals, increasing access
to healthy and affordable food through systems and policy changes, and access to food assistance
programs. For example, retail venues that sell healthier food can impact diet and nutrition. Low
income communities may have less access to healthier food choices. Marketing also has a major
influence on people’s food choices (Healthy People 2020).
89
Healthy People 2020 objectives related to healthier diet and access to healthy food include:
 Increase the proportion of schools that offer nutritious foods and beverages outside of
school meals
 Increase the proportion of schools that do not sell or offer calorically sweetened beverages
 Increase the proportion of schools districts that require schools to make fruits and vegetables
available whenever other foods are offered or sold
 Increase the number of states that have nutrition standards for food and beverages provided to
school aged children in childcare
AJH initiated several projects to improve access to healthy foods, reduce food insecurity, and enhance
communication about existing resources. As part the CHNA process, members of the community
health department collected contact information on all Montgomery County food pantries and posted
this list on Abington's intranet to enable AJH colleagues to refer those in need. AJH shared this list
with other non-profits and key community stakeholders so more food insecure residents can benefit
from a convenient food pantry. AJH’s Nutrition Department is involved with several initiatives
including the Summer Farm Stand, a six week summer fresh fruit and vegetable booth in the hospital
cafeteria and collaborating with Abington Family Medicine to include a dietitian in its patient
centered medical home model. Furthermore, Abington Hospital eliminated all fryers and AbingtonLansdale Hospital is in the process of removing this cooking method. A future endeavor will use new
digital menu boards in the cafeteria to highlight nutritional values and the selection will include
healthy food themes.
PHMC Household Health Survey 2015 findings indicate that approximately 95% of residents are
satisfied with the quality of groceries available in their neighborhoods.
% Reporting Fair/Poor Quality of Groceries in
Neighborhood
5.5
5.6
6.5
5.6
4.3
4.2
4.8
1.6
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
Very few residents in Abington's CB areas report difficulty finding fruit and vegetables in their
neighborhoods.
90
3.0
% Who Have Difficulty Finding Fruit and Vegetables
2.5
2.0
1.5
1.0
0.5
0.0
North
Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
Difficult
0.1
1.8
0.1
1.5
1.2
2.5
1.7
1.4
Very Difficult
0.0
0.0
0.0
0.2
0.1
0.0
0.0
0.8
PHMC Household Health Survey 2015
Although access to fruits and vegetables is not problematic, on average 50% of adults in Abington's
CB areas report eating less than 3 servings of fruit and vegetables daily. Central Bucks is the
exception, with almost two thirds of adults reporting that they eat at 3 or more servings of fruits and
vegetables each day.
# Servings of Fruits & Vegetables per Day
15.1
9.6
33.7
38.0
18.4
16.4
26.4
29.3
34.9
20.3
18.4
15.1
31.0
32.9
33.4
48.3
47.1
48.6
38.9
49.0
47.5
4.8
North Penn Indian Valley
42.4
50.6
32.8
4.2
William
Tennent
3.7
Central Bucks
Lower
Eastern
2.8
Abington Upper Dublin Bucks/ Mont
0
1-2
3-4
5+
PHMC Household Health Survey 2015
Adults in Indian Valley and Lower Eastern are more likely to eat food from a fast food restaurant
compared to adults in Bucks/Mont. Fewer than 4% report eating fast food 3 or more times a week.
91
% Respondents
# Times Eat Fast Food in Per Week
40
35
30
25
20
15
10
5
0
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
3+
0.6
1.5
0.8
2.6
3.4
2.9
2.1
3.5
1-2
31.3
33.0
24.9
23.3
30.9
19.2
20.4
27.4
PHMC Household Health Survey 2015
The table below provides information on poverty (<200% FPL) and race/ethnicity related to healthy
eating in Bucks/Mont. Overall, poverty (<200% FPL) and minority race/ethnicity appear to
negatively impact healthy eating lifestyles.
Healthy Eating Behaviors by Poverty and Race/Ethnicity in Bucks/Mont
< 200% > 200% % White % Black
FPL
FPL
nonnonLatino
Latino
Ate less than 3 servings of
64.0
49.0
50.4
60.8
fruits/vegetables daily in past week
Difficult/very difficult to find fruit
5.2
1.7
2.0
4.2
in neighborhood
Eat fast foods 3+ times/week
4.3
3.2
3.4
5.2
% nonLatino
Asian
55.2
%
Latino
1.1
3.8
0
3.9
56.0
PHMC Household Health Survey 2015
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to healthy eating included:

Increasing access to healthy, affordable food
o Lifestyle, habit, culture, unfamiliarity with healthy foods, and access to healthy foods
close to home are factors related to healthy eating
o Socialization and healthy meals close to home at an affordable price are important for
seniors
o The morbidity section on obesity also provides key informant and focus group comments
about healthy eating
Recommendations included:
1) Referrals to United Way's 2-1-1 SEPA including food banks
2) Share an asset map that includes food resources with AJH staff
92
Alcohol and other Substance Abuse
Speaking of drugs: "We mirror any other suburban community outside of a city, i.e., Chicago" (Key
informant)
Dr. Loren Robinson "sees a heroin-related issue almost every shift at Lansdale that is a big change
from even a few years ago. 'The heroin epidemic is a huge problem for Philadelphia and our state' "90
Almost 95 percent of people with substance use problems are considered unaware of their problem
and as a result many do not seek care. Substance abuse has a major impact on individuals, families,
and communities. The effects of substance abuse significantly contribute to costly social, physical,
mental, and public health problems including teenage pregnancy, HIV/AIDS, other sexually
transmitted diseases, domestic violence, child abuse, motor vehicle crashes, physical fights, crime,
homicide and suicide (Healthy People 2020). Binge drinking is particularly problematic. The
Healthy People 2020 objective for binge drinking is to reduce the proportion of adults aged 18+ who
engaged in binge drinking in the past 30 days to 24.4%. For adolescents age 12 to 17, the Healthy
People goal is to reduce the proportion of students who report using alcohol or any illicit drug in the
past 30 days to 16.6%.
Pennsylvania leads the country in drug overdose deaths among men ages 19 to 25; within
Pennsylvania, Bucks County had the highest rate at 73.3 per 100,000 male residents in that age group,
and Montgomery had the second highest rate at 41.6.91 These rates far exceed the Healthy People
2020 substance abuse goal of 11.3 all-age deaths per 100,000 population.
While the percentage of youths ages 12 to 17 nationally who abuse most drugs has decreased,
marijuana use is edging upward, from 6.2% in 2002 to 8.4% in 2014. Additionally, the potency of
marijuana has increased. Daily marijuana use by teens is associated with 60% lower high school
graduation rate and 7 times higher suicide rates.92
Healthy People 2020 also desires to increase the number of Level I and Level II trauma centers and
primary care settings that implement evidence-based alcohol Screening and Brief Intervention.
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to alcohol and other substance use included:




Need to address alcohol and marijuana use
o Access to gateway drugs among youth aged 14-18 (marijuana and alcohol)
o Kids make fun of health education in the school system
o Prescription drug abuse and heroin are problems for teens and adults. Resources to aid
recovery are limited. Law enforcement and government agencies are aware of the issue
o In Bensalem near the casino, "DUIs are up 900%"
o Resources to screen for drug and alcohol abuse and functional alcoholics are lacking
Heroin, both with and without Fentanyl, is "cheap and easy to get"
Mixing of prescription drugs among the total population and older adults is common. Those
on high dose narcotics and other pain management medications are especially at risk
Babies are detained because of their mothers' drug abuse; heroin is an issue
93



Mental health issues such chronic stress, anxiety and depression can lead to addictions
There are not enough drug and alcohol resources or beds
There are not enough behavioral and addiction counselors
Recommendations included:
1)
2)
3)
4)
5)
6)
7)
Increase access to constructive activities for youth and adolescents
Review drug education curriculum in schools and revise as needed
Need more education in schools, beds, and counselors
Need education regarding mixing prescription drugs
Implement drug screening for all patients, not just those in clinic settings
Create a fact sheet on AJH Behavioral Health to serve as a resource
Utilize the expertise of a navigator who has knowledge of insurance coverage and
connections with community services
Health Behaviors and Adolescents
The leading causes of illness and death among adolescents and young adults are largely preventable.
During adolescence behavioral patterns are established that can affect current health status and impact
risk for developing chronic diseases in adulthood. Social and environmental factors such as family,
friends, school, neighborhood, and social norms can support or challenge adolescents’ health and
well-being. Addressing the positive development of young people facilitates their adoption of healthy
behaviors and helps to ensure a healthy and productive future adult population.
Except where noted, the information provided in this section is based the 2013 Youth Behavior Risk
Surveillance (YBRS) for high school students.93 This data is being used because it is self-reported by
youth, not their parents and is therefore more likely to represent actual behaviors of adolescents in the
United States.
Tobacco Use
 15.7% of students report being current smokers, down from a high of 21.9% in 2003
 8.6% of students report smoking 10 or more cigarettes per day
 9.3% of students report initiation of smoking before age 13
 52% did not try to quit smoking in the past 12 months
 E-cigarette use (use on at least 1 day in the past 30 days) among high school students
increased from 4.5% in 2013 to 13.4% in 2014, rising from approximately 660,000 to 2
million students. Among middle school students, e-cigarette use more than tripled from 1.1%
in 2013 to 3.9% in 2014—an increase from approximately 120,000 to 450,000 students94
Alcohol Use
 34.9% of students reported alcohol use within the last 30 days
 20.8% reported binge drinking (5 or more drinks in a row)
 18.6% of students report drinking alcohol for the first time (more than a few sips) before age
13
94
Use of other drugs
 23.4% of students report current marijuana use
 Ever used: prescription drugs without a prescription (17.8%), inhalants (8.9%), hallucinogenic
drugs (7.1%), ecstasy (6.6%), cocaine (5.5%), methamphetamines (3.2%), steroids without
prescription (3.2%), heroin (2.2%)
 22.1% of students reported being offered or sold drugs on school property
Body Weight, Nutrition and Physical Activity
 13.7% of students are classified as obese based on self-reported height and weight
 16.6% are classified as overweight based on self-reported height and weight
 13% did not eat for 24 hours or more to lose weight or keep from gaining weight
 5% reported eating no fruits and 6.6% reported eating no vegetables in the past 7 days
 27% report daily consumption of non-diet soda
 15.2% reported zero days of > 60 minutes of physical activity in the past week, including
more females than males
 32.5% watched three hours or more of TV daily: more African American students (53.7%)
than Hispanic (37.8%) and non-Hispanic whites (25%)
Safety and Violence
 7.6% never or rarely wear seat belts
 87.9% of students report never or rarely wearing a bicycle helmet while riding a bike
 49% of juniors and 60.3% of seniors report ever texting or emailing while driving
 5.9% carried a weapon on school grounds
 24% were in a physical fight during the last year
 7% stayed home from school within the past year due to safety concerns
 16.8% reported being bullied at school
 14.9% reported being bullied electronically
 18.2% seriously considered suicide
 7.5% reported a suicide attempt within the last year
Sexual Activity
 54.6% report ever having sexual intercourse: 30% of 9th graders and 64.1% of seniors
 5.6% report sexual intercourse prior to age 13
 Among sexually active students:
o 59.1% used a condom during last sexual intercourse
o 13.7% did not use any method of birth control during last intercourse
o 22.4% reported use of alcohol and/or other drugs prior to last sexual intercourse
o 14.7% were never taught about AIDS or HIV
Healthy People 2020 objectives for adolescents include:


Increase the proportion of adolescents who have had a wellness checkup in the past 12 months
to 75.6%
Increase the proportion of adolescents who participate in extracurricular and/or out-of-school
activities to 90.6%
95















Increase the proportion of students who graduate with a regular diploma 4 years after starting
9th grade to 82.4%
Decrease school absenteeism among adolescents due to illness or injury
Reduce the proportion of students who report using alcohol or any illicit drug in the past 30
days to 16.6%.
Reduce the proportion of adolescents who have been offered, sold, or given an illegal drug on
school property to 20.4%
Increase the proportion of middle and high schools that prohibit harassment based on a
student’s sexual orientation or gender identity to 92.2%
Reduce the percent of adolescents aged 12 to 19 years who are considered obese to 16.1%
Increase fruit and vegetable consumption
Reduce the percent of adolescents in grades 9 through 12 who smoked cigarettes in the past
30 days to 16%
Increase the percent of adolescents who meet the current physical activity guidelines for
aerobic physical activity to 31.6%
Increase the percent of adolescents in grades 9 through 12 who viewed television, videos, or
played video games for no more than 2 hours a day to 73.9%
Increase the percent of adolescents in grades 9 through 12 who used a computer or played
computer games outside of school (for non-school work) for no more than 2 hours a day to
82.6%
Reduce the percent of students in grades 9 through 12 who reported that they engaged in
physical fighting in the previous 12 months to 28.4%
Reduce the percent of students in grades 9 through 12 who reported that they were bullied on
school property in the previous 12 months to 17.9%
Reduce the percent of students in grades 9 through 12 who reported that they carried weapons
on school property during the past 30 days to 4.6%
Increase the percent of motor vehicle drivers and right-front seat passengers that used safety
belts to 92%
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to healthy behaviors and adolescents included:









Need constructive things to do. "If not they get into trouble."
Rise of children on the autism spectrum including Aspergers
Sexual behavior among young people
Rising asthma rates among youth
Health plans not always covering treatment for allergies
Young people need healthy eating/exercise combination
Students with limited resources need eye exams and glasses
Bike safety, helmet safety are "not always on the radar." Need more education on how to
safely ride.
School related issues
o The Abington School District reports that drug and alcohol, heroin, and pills are problems.
Others are concerned with smoking.
96
o School districts cutting more in classroom. There is less support in classroom- not as many
aides or volunteers. There is less volunteerism. Greater focus on test scores. Many single
parent families with competing responsibilities limit parental support. Children diagnosed
with autism need support.
o Well rested and fed children results in success for school district
o Grant funding for Abington School District Health/Physical Education staff is expiring;
increasing obesity is a concern
Recommendations included:
1) Explore the possibility for Wills Eye to conduct eye screenings in Abington.
2) Increase youth access to constructive, positive activities in the community
Communication
Between approximately 20 and 40% of Abington CB area residents did not use social media in the
past three months. The highest use was in Central Bucks, the area with the youngest population.
% Not Using Social Media in the Past 3 Months
41.6
38.5
32.9
31.3
35.0
34.7
36.1
Abington
Upper
Dublin
Bucks/
Mont
19.5
North Penn
Indian
Valley
William
Tennent
Central
Bucks
Lower
Eastern
PHMC Household Health Survey 2015
E-mail and postal mail are the preferred ways to receive health or social service information, with
social media a distant third choice in some Abington CB areas.
97
Preferred Way to Receive Health or Social Service Information
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other*
Television
Newspapers
Social Media **
Postal Mail
Email
* Other includes
telephone, text
messaging, and other
North
Penn
Indian William Central Lower Abington Upper
Valley Tennent Bucks Eastern
Dublin
Bucks/
Mont
** such as Facebook or
Twitter
PHMC Household Health Survey 2015
Issues, challenges, unmet needs and priorities identified by key informants and focus group
participants related to communication included:



Individuals with limited social or community networks cannot substitute social media for
personal contact. Social media or virtual visits without in-person contact leads to depression
and isolation.
Social media is for young people.
Not everyone uses social media
Recommendations included:
1) Explore the potential for Abington Police Department to collaborate on Facebook Chat
or other social media to educate the public; ability to publicize to broader audience;
social media
2) AJH should use social media to post educational alerts
3) Explore using social media for health messages on lifestyle and behavioral changes.
AJH has an opportunity to utilize new and future social media strategies to reach an
extended audience for prevention and wellness education messages
98
Special Populations – Older Adults, Immigrants and Refugees, Homeless
Older Adults
Older adults are among the fastest growing age groups, and the first “baby boomers” (adults born
between 1946 and 1964) turned 65 in 2011. Older adults are at high risk for developing chronic
illnesses and related disabilities including diabetes mellitus, arthritis, congestive heart failure, and
dementia. Illness, chronic disease, and injury can create physical and mental health limitations in
older adults, affecting their ability to live independently at home. Regular physical activity is a
protective factor for such declines. While most adults want to age in place and remain in their homes
for as long as possible, the supports they need to do so may not be available. Caregivers are often
family members or friends who volunteer and may not be prepared for the stressors of caregiving.
Elder abuse by a caregiver has unfortunately become more common with up to 2 million older adults
affected (Healthy People 2020).
The Healthy People 2020 objectives on older adults focus on:
 Increased adherence to a core set of clinical preventive services
 Increased older adult confidence in managing chronic health conditions
 Increased diabetes self-management benefits to 2.2%
 Increased physical activity among those with reduced physical or cognitive impairment to
35.9%
 Increased proportion of the healthcare workforce with geriatric certification (target –
physicians 3%; psychiatrists 4.7%; registered nurses 1.5%; physical therapist 0.7%; registered
dietitians 0.33%)
 Reducing ED visits due to falls (Target: 4,711.6 ED visits per 100,000 due to falls among
older adults)
Bucks and Montgomery counties have Area Agencies on Aging, and in accordance with
Pennsylvania Act 70 and the Older Americans Act, each must produce an Area Plan for Aging
Services every four years. For the years 2012-2016, the Bucks County Area Agency on Agency
established three main focus areas:



to help ensure that Pennsylvanians will age and live well and that communities will be
designed to help them age and live well
to move the discussion away from Institution vs. Home and Community-Based Services and
to refocus on access to the appropriate services and care for the right time, with the right
intensity, in the right setting, for the right duration
to bring the best of Pennsylvania to Pennsylvanians95
To meet its goals, the Bucks County plan describes the following long term services and supports:
The Information and Referral department typically receives more than 30,000 calls annually from
consumers, families, professions, and other stakeholders seeking services and supports for older
adults.
99
Nutritional Services provided meals to an average of 2,979 consumers per year from 2007 to 2011.
Hot meals are served at lunch time in the Congregate Meal program at 11 senior centers and 2
satellite centers, Monday through Friday. The Home Delivered Meals Program delivers to those in
need who are unable to attend the senior center lunches. In fiscal year 2011-12, a total of 113,822
home delivered meals and 75,938 congregate meals were expected to be provided. The goal is to
satisfy 1/3 of food insecure seniors' recommended dietary allowance.
To promote community involvement and independence, partially subsidized transportation is
available through the Shared Ride Program to take individuals age 65+ to destinations such as senior
centers, medical facilities, human service agencies, libraries, adult day services, pharmacies, banks,
retired and senior volunteer program assignments, and food shopping. In fiscal year 2011-12, 1,600
eligible residents received 70,935 trips to approved destinations.
The APPRISE Program offers health insurance counseling to older adults and their families. In fiscal
year 2011-12, 56 community presentations were completed and 2,000 consumers received benefits
counseling.
The Prime Time Health Program provides information on a wide range of subjects to encourage
disease prevention and health promotion such as falls prevention, exercise classes, health screenings,
medication and alcohol use and misuse, and healthy cooking. In fiscal year 2011-12, educational
literature regarding Project Meds was distributed to 1,100 people at 15 health fairs across the county.
The Employment Assistance Program assists unemployed adults age 55+ with incomes that do not
exceed 125% of the federal poverty level with work based training opportunities.
Volunteer Opportunities with a variety of non-profit organizations are available. In 2011, 646
volunteers provided over 116,600 hours of service to 138 partner agencies, accounting for $2.5
million of volunteer service.
Senior Community Centers facilitate the social, emotional, and physical well being of older adults. In
FY 2011-12, more than 286,000 visits to senior centers were expected.
Long Term Care uses case managers to assess residents for services such as medical assistance
funding for nursing facility care, in-home services, adult day care, personal emergency response
systems, home delivered meals, home modifications, counseling and behavioral health needs, and
medical equipment and supplies. Subsidies depend on income level.
The Nursing Home Transition offers alternatives to residing in an institutional setting by offering
supports to enable residents to transition to the community.
Older Adult Protective Services investigates reports alleging abuse, neglect, financial exploitation,
and abandonment of older adults. From fiscal year 2007-08 through fiscal year 2010-11, 1,141
reports were completed with 170 cases substantiated.
Ombudsman investigates and helps resolve complaints related to the health, safety, and rights of older
residents receiving long term care services.
100
Legal Services provides benefits and rights counseling and legal representation to assist older adults.
The five main focus areas in the Montgomery County Office of Aging and Adult Services (MCAAS)
plan for 2012-2016 are:





work collaboratively to enhance the existing system of coordinated and comprehensive
services and programs to support stronger communities for older and disabled adults who
choose to age at home in a community setting
provide enhanced access to information, benefits, and programs for older and disabled adults
seeking to make informed choices regarding their options along the long term care continuum
support health and wellness programs for older and disabled adults to enhance each person's
mental and physical wellbeing within their communities
support efforts to enhance the quality of life for older residents who are most at risk
continue to support an individual's right to choose home and community-based options,
despite shrinking public resources available in this current economic environment96
There is a concern that existing resources will not be able to adequately respond to the growing
numbers of aging residents. Trends, such as aging Baby Boomers, the increased numbers of nonEnglish speaking older adults, particularly in the Asian communities, and the needs of grandparents
as caregivers, inform the MCAAS plan.
Population trends: The number of the most frail elderly age 85+ grew 28% between 2000 and 2010,
and the number of centenarians increased 44% from 147 to 221 during this time frame. Although
Philadelphia County has a larger number of adults over age 60, Montgomery County has a higher
percentage and projections indicate that Montgomery County will continue to be the oldest county in
southeastern Pennsylvania. A significantly higher percentage of lower income households exists for
those over age 65, as older residents deal with the financial pressure from living in a region with a
high cost of living, and many on a fixed income are challenged to meet increased costs for the basics
needed to remain at home. The gender mix for those over age 65 is 60% female and 40% male. The
needs of older women living alone continues to be a concern, as gender relates to poverty and abuse.
MCAAS also notes that according to reliable sources, the numbers of Asian and Hispanic individuals
has increased more than as reported in the official census. The increasing population of foreign-born
and non-English-speaking elders places new demands on service providers for interpretation,
translation, and cultural sensitivity.
Housing: The majority of Montgomery County older adults live in a private home, apartment, or
continuing care retirement community. They report their desire to remain at home in the community,
and cite affordable housing as a major concern for the future. Many of the age-restricted housing
projects/communities are built on multiple levels, and/or are located in areas distant from services,
transportation, or medical care. More local and county-wide planning efforts to meet the needs of
older people needing specialized housing are needed, and Montgomery County continues to support
the work of the Delaware Valley Regional Planning Commission to create more "aging friendly"
communities.
Grandparents as caregivers: The estimated number of grandparents living with one or more of their
own grandchildren under age 18 increased 8% over the decade ending in 2010, when more than
11,000 grandparents were estimated to be in this living situation. For those with limited resources,
101
the economic squeeze is noteworthy, since many older caregivers make choices related to self care
versus care for the children in their homes.
MCAAS plans to work with hospitals and long term care facilities to promote supportive care
transitions, reduce hospital readmissions, and strengthen health promotion efforts for the aging
residents of the county.
Health Status
Health status data for older adults is from the PHMC Household Health Survey conducted in 2015.
Abington-Lansdale CB areas are combined because the number of older adults who participated in
the survey from each community was too small to be analyzed individually.
Access to Care
Fewer older adults in Eastern Montgomery report having a regular source of care. North Penn/Indian
Valley is the closest to the Healthy People 2020 goal of all people 65+ having a specific source for
ongoing care.
%Age 60+ With Regular Source of Care
Healthy People 2020 Target for a specific source for ongoing care= 100%
95.7
94.2
93.8
89.4
North Penn/ Indian
Valley
William Tennent/
Central Bucks
Eastern Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
The majority in Bucks/Mont (58.1%) saw their health care provider three or more times in the
previous year. Fewer (49.3%) from North Penn/Indian Valley reported visiting their provider 3 or
more times in the past year. Very few adults (5.2%) living in Bucks/Mont did not see a health care
provider in the past year.
102
Age 60+ # of Visits to Health Care Provider in Past Year
49.3
64.5
46.3
35.5
4.4
North Penn/ Indian
Valley
56.9
58.1
39.1
36.6
3.9
5.2
William Tennent/ Eastern Montgomery
Bucks/Mont
No visits
1 to 2
3 or more
Central Bucks
PHMC Household Health Survey 2015
Older adults living in Eastern Montgomery were more likely to have gone to the ED (29.3%) in the
past year compared to older adults in North Penn/Indian Valley (23.9%) and Bucks/Mont (28.0%).
However, older adults in North Penn/Indian Valley were more likely to have had 3 or more visits to
the ED compared to Bucks/Mont and the other Abington CB areas.
100%
80%
Age 60+ # Visits to ER in Last Year
8.1
3.1
3.0
4.3
15.8
25.5
26.3
23.7
76.1
71.3
70.7
72.0
Eastern
Montgomery
Bucks/Mont
60%
40%
20%
0%
North Penn/ Indian William Tennent/
Valley
Central Bucks
0
1-2
3 or more
PHMC Household Health Survey 2015
Although less than 5% of adults age 60+ reported cancelling a doctor’s appointment because of
transportation problems, a key informant cited transportation for the aging population "to get where
they need to go including physicians and hospital appointments" as a key concern. Abington's Muller
Institute for Senior Health provides van service to hospital outpatient services for patients who live
within an 8 mile radius of Abington Hospital.
103
% Age 60+ Who Didn't Go to a Needed Doctor
Appointment Due to Transportation Problems
4.7
4.6
3.8
3.6
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
About twice as many older adults in William Tennent used transportation services compared to the
other Abington CB areas.
% Age 60+ Used Transportation Services in
Past Year
11.6
6.9
5.8
North Penn/
Indian Valley
5.3
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Awareness of transportation services varies; more than 17% in North Penn say they are not aware of
transportation services, while only 4.2% from Eastern Montgomery are unaware. Unawareness does
not appear to have a direct correlation to utilization of transportation services.
104
% Age 60+ Unaware of Transportation
Services
17.2
9.6
9.2
4.2
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Cost of health care and medications was also problematic for 4 to 5% of older adults in Abington's
CB areas.
% Age 60+ Sick Who did not Seek Care Due to
Cost
5.0
4.8
4.1
3.4
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
In Eastern Montgomery, 1 in 10 adults age 60+ did not purchase needed medication due to cost.
% Age 60+ Who did not Obtain Prescription
Medicine due to Cost
10.0
7.4
7.1
4.5
North Penn/ Indian William Tennent/
Valley
Central Bucks
PHMC Household Health Survey 2015
105
Eastern
Montgomery
Bucks/Mont
Compared to Bucks/Mont and the other Abington CB areas, slightly fewer older adults in Eastern Montgomery
were unaware of PACE, Pennsylvania's Pharmaceutical Assistance Contract for the Elderly. Promoting this
program will assist those who have hardship paying for prescriptions. In Montgomery County,
offices located in Abington/Willow Grove, Lansdale, Pottstown and Norristown provide access,
information, and navigation to county and state programs including PACE. AJH’s Community
Health department disseminates such benefit information to case managers, patient centered medical
home care managers, home care personnel, and social workers. Although the North Penn Foundation
supports several nonprofits to provide navigators for health insurance benefits, there is continued
opportunity to educate, promote and communicate PACE to health professionals, social service
agencies, and area nonprofit organizations.
% Age 60+ Unaware of PACE
21.6
20.9
20.0
18.3
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Chronic Disease
Obesity is an underlying cause of hypertension, heart disease, cancer, asthma and diabetes. Rates of
chronic disease among older adults in Abington's CB areas vary. Obesity rates among older adults in
Abington CB areas are below the Healthy People 2020 target. More than 6 in ten are obese or
overweight.
106
70
60
50
40
30
%20
10
0
%Age 60+ Obesity Level
North Penn/
Indian Valley
William
Tennent/
Central Bucks
Eastern
Montgomery
Bucks/ Mont
Overweight
46.3
41.9
34.2
38.5
Obese
26.9
24.1
26.8
27.8
HP 2020 Target
30.5
30.5
30.5
30.5
PHMC Household Health Survey 2015
Ever had asthma rates range from 4.9% in North Penn/Indian Valley to 14.6% in William
Tennent/Central Bucks.
% Age 60+ Ever Had Asthma
14.6
10.9
8.9
4.9
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Ever had high blood pressure rates are more consistent, and lower than Bucks/Mont. Not
surprisingly, rates are much higher than the total population.
%Age 60+ Doctor Ever Told have High BP
Healthy People 2020 Maximum Target for All Ages = 26.9%
51.7
45.9
45.3
42.2
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
PHMC Household Health Survey 2015
107
Bucks/Mont
More than 90% of adults age 60+ with hypertension report taking medication for this condition.
%Age 60+ Currently Taking Medication for
High Blood Pressure
98.5
96.2
90.9
94.6
Healthy People 2020 Target for All Ages = 69.5%
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Approximately 9 of 10 take their blood pressure medication as prescribed. Very few take it less than
90% of the time.
%Age 60+ Taking High BP Medications as Prescribed
100%
80%
North Penn/
Indian Valley
William
Eastern
Tennent/
Montgomery
Central Bucks
Bucks/Mont
Less than 90% of the time
0.7
1.9
0.3
2.9
Nearly all of the time (90%)
10.7
8.4
6.7
5.0
All the time (100%)
88.6
89.7
93.0
92.0
PHMC Household Health Survey 2015
As noted previously, a reduction in dietary salt intake has been documented to lower blood pressure
and older adults are sensitive to the blood pressure-lowering effects of a decreased salt intake.
Almost two thirds of adults age 60+ report watching or reducing their sale intake.
108
% Age 60+ Currently Watching or Reducing
Salt Intake
67.6
65.2
64.3
61.6
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Between two thirds and three quarters of these adults age 60+ believe that salt intake is somewhat or
very harmful to health.
100%
80%
% Age 60+ Who Think Too Much Salt is
Harmful to Health
37.4
30.0
35.7
35.7
40.9
38.8
20.2
3.3
17.6
7.8
60%
40%
36.8
20%
16.5
9.4
0%
37.5
20.8
11.7
North Penn/ William Tennent/
Eastern
Bucks/Mont
Indian Valley
Central Bucks
Montgomery
Not at all harmful
A little harmful
Somewhat harmful
Very harmful
PHMC Household Health Survey 2015
The majority think there is a link between too much salt and risk of stroke. However, in William
Tennent/Central Bucks, there is a lower percentage who think the risk is high, and a higher proportion
who do not think there is a link. As noted earlier, stroke mortality increased in Bucks County
between 2010 and 2012, and salt intake is correlated with risk of stroke.
109
% Age 60+ Who Think Too Much Salt Affects
Risk of Stroke
45.5
23.4
43.6
39.5
33.7
30.8
40.6
26.6
27.9
36.0
22.7
North Penn/ Indian William Tennent/
Valley
Central Bucks
29.6
Eastern
Bucks/Mont
Montgomery
Not at all/ A little Some A lot
PHMC Household Health Survey 2015
Over 80% of adults age 60+ report buying items with reduced salt. Buying patterns do not appear to
directly correlate with beliefs about the relationship of dietary salt and health risks. For example,
respondents from North Penn/Indian Valley reported the most concern about salt and risk of stroke
and the highest percentage who do not buy reduced sodium products.
%Age 60+ Buying Items Labeled "Low Salt' or
'Low Sodium'
19.3
40.1
40.6
12.4
12.0
14.0
47.3
39.4
38.3
48.5
47.6
40.3
North Penn/ Indian William Tennent/
Eastern
Valley
Central Bucks
Montgomery
Always/Often
Sometimes/Rarely
Bucks/Mont
Never
PHMC Household Health Survey 2015
Ever had diabetes rates range from 12.2% in North Penn/Indian Valley to 21.3% in Eastern
Montgomery.
110
% Age 60+ Ever Had Diabetes
21.3
12.2
19.0
14.3
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Most older adults have never been tested for HIV. HIV screening in the older adult population may
be warranted.
% Age 60+ Never Tested for HIV
85.8
83.2
82.5
79.5
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Older adults in William Tennent/Central Bucks have a significantly higher rate of diagnosed mental
health condition compared to Bucks/Mont and the other Abington CB areas. Older adults in North
Penn/Indian Valley and Eastern Montgomery have much lower rates of diagnosed mental health
conditions than the total adult population, suggesting that there may be undiagnosed cases.
% Age 60+ With Diagnosed Mental Health
Condition
23.8
10.1
7.1
North Penn/
Indian Valley
3.2
William Tennent/
Central Bucks
PHMC Household Health Survey 2015
111
Eastern
Montgomery
Bucks/Mont
Major depression among older adults in William Tennent/Central Bucks is also much more prevalent
than in the other Abington CB areas and Bucks/Mont. The CDC CHSI methodology rated older adult
depression in both Bucks and Montgomery Counties in the least favorable quartile when compared to
peer counties.
% Age 60+ With Signs of Major Depression
12.7
8.5
4.2
3.5
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
However, older adults in the Abington CB areas are less likely to be receiving treatment for their
mental health conditions than in Bucks/Mont. The inability of the formal aging system to respond to
mental health issues will remain a barrier to serving the older adult population.
% Age 60+ Not Currently Receiving Treatment
for a Mental Health Condition
56.4
52.8
44.7
34.9
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Alzheimer's and dementia are chronic conditions affecting the older adult population. Alzheimer’s
disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills,
and eventually the ability to carry out the simplest tasks. In most people with Alzheimer’s,
symptoms first appear in their mid-60s. Estimates vary, but experts suggest that more than 5 million
Americans may have Alzheimer’s. Alzheimer's disease is currently ranked as the sixth leading cause
of death in the United States, but recent estimates indicate that the disorder may rank third, just
behind heart disease and cancer, as a cause of death for older people.97 To address these conditions,
the Muller Institute for Senior Health initiated sessions on Alzheimer’s and dementia education and
trained more than 500 AJH employees, clinical and medical staff.
112
Ethnic minority background and income are associated with risk for functional health impairments,
and the combination of poverty and ethnic minority background appears to increase that risk. More
than a fifth of older adults in Bucks/Mont and more than a quarter in William Tennent/Central Bucks
have an Instrumental Activity of Daily Living (IADL) that limits their everyday functioning.
% Age 60+ With IADL Limitation
27.0
21.0
North Penn/
Indian Valley
21.2
17.7
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Of those with an IADL, those living in William Tennent/Central Bucks had more limitations than
older adults living in the other areas.
% Age 60+ Number of IADL Limitations
3.9
1.4
4.8
5.2
4.8
8.8
3.3
1.7
3.6
10.1
9.0
9.1
9.1
Eastern
Montgomery
Bucks/Mont
North Penn/ Indian William Tennent/
Valley
Central Bucks
4.1
3.4
4.7
1
2
3
4-7
PHMC Household Health Survey 2015
Deficits in IADLs vary by type of IADL and location. For most IADLs, older adults living in
William Tennent/Central Bucks had the greatest need for assistance.
113
%Age 60+ Completely Unable or Need Some Help To:
Use phone
Walk
Shop
Prepare meals
Do housework
Take medicine
Handle money
North Penn/
Indian Valley
1.9
7.8
9.7
2.4
10.9
4.1
3.0
W. Tennent/
Central Bucks
2.9
18.8
17.1
3.0
15.3
3.0
6.7
Eastern
Montgomery
0.1
6.0
8.1
5.7
14.4
0.2
0.4
Bucks/
Mont
1.5
9.9
10.5
5.0
15.8
2.4
3.3
PHMC Household Health Survey 2015
Ten percent of older adults in Bucks/Mont have at least one Activity of Daily Living (ADL) that
limits their functioning, and the percentages with limitations in Abington CB areas is less.
% Age 60+ With ADL Limitation
10.2
9.5
7.7
3.7
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Of those with an ADL, those living in William Tennent/Central Bucks had the highest proportion of
older adults with 3 or more ADLs.
% Age 60+ Number of ADL Limitations
4.0
0.2
2.1
0.6
1.3
1.9
1.3
0.3
6.0
1.9
6.3
3.6
1.4
North Penn/ Indian William Tennent/
Valley
Central Bucks
PHMC Household Health Survey 2015
114
Eastern
Montgomery
Bucks/Mont
1
2
3
4-7
Older adults in Abington CB areas receive volunteer help with IADLs at rates slightly higher than
Bucks/Mont.
% Age 60+ With Volunteer Help with IADLs
34.3
33.9
32.2
31.0
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
North Penn/Indian Valley and William Tennent/Central Bucks older adults received volunteer help
with ADLs more often than Bucks/Mont seniors.
% Age 60+ With Volunteer Help with ADLs
37.4
35.5
North Penn/
Indian Valley
William Tennent/
Central Bucks
22.7
23.1
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Frequency of receiving volunteer help for either IADLs or ADLs varies greatly.
% Age 60+ Frequency of Getting Volunteer Help
29.9
40.5
8.6
9.2
44.3
82.3
55.7
23.9
23.3
52.8
29.5
North Penn/ Indian
Valley
Everyday
William Tennent/
Eastern
Bucks/Mont
Central Bucks
Montgomery
Several times a week
Once a week or less
PHMC Household Health Survey 2015
115
Older adults in Eastern Montgomery received paid help with ADLs slightly more than other areas.
% Age 60+ With Paid Help with ADLs
8.6
9.0
William Tennent/
Central Bucks
Eastern
Montgomery
7.7
5.3
North Penn/
Indian Valley
Bucks/Mont
PHMC Household Health Survey 2015
They also reported the highest rate of coverage with long term care insurance.
% Age 60+ with Long Term Care Insurance
34.4
29.5
27.2
25.5
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Although at least 25% of older adults reported long term care coverage, only residents in Eastern
Montgomery and Bucks/Mont said they used it for home care services.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age 60+ Payers of Home Care Services
Agency
Out-ofpocket
Private
Insurance
Medicaid
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
PHMC Household Health Survey 2015
116
Bucks/Mont
Medicare
Preventive Health Care Services
Women over age 60 in Abington's CB areas had a PAP test in the previous 3 years at rates well below
the Healthy People 2020 target of 93% for all age women. Less than half of North Penn/Indian
Valley women had a PAP test within the past 3 years.
Age 60+ % Having Pap Test within 3 Years
Healthy People 2020 Target = 93%
73.6
70.8
61.5
49.3
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Only 26.7% of Eastern Montgomery women aged 60+ had a breast exam in the prior year compared
to 36.4% of older women in Bucks/Mont. Rates of breast exam by professionals for older women
were somewhat lower than for all age women.
% Age 60+ No Breast Exam by Health Care
Professional Within the Past Year
33.8
37.9
36.4
26.7
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
However, older adult women in Eastern Montgomery were most likely to have had a mammogram in
the previous two years (87.3%), exceeding the Healthy People 2020 target of 81.1%.
117
Age 60+ # Time Since Last Mammogram
18.6
21.4
13.8
9.4
63.0
69.2
12.7
24.1
16.3
12.6
71.0
63.3
North Penn/ Indian William Tennent/ Eastern Montgomery
Bucks/Mont
Valley
Central Bucks
one year or less
more than one year, up to 2 years
More than 2 years
Healthy People 2020 Goal = increase % of women aged 50-74 years who had a
mammogram based on the most recent guidelines to 81.1%
PHMC Household Health Survey 2015
As mentioned in the earlier all ages section on Preventive Care and Early Detection of Disease, older
adults in North Penn/IndianValley were less likely to have had a colonoscopy in the past 10 years
compared to adults in the other Abington CB areas and Bucks/Mont. The Healthy People 2020 goal
is for 70.5% of adults aged 50 to 75 years to have a colorectal cancer screening based on the most
recent guidelines.
% Age 60+ Never Had or > 10 Years Since
Last Sigmoidoscopy/Colonscopy
24.7
North Penn/
Indian Valley
22.3
2.2
5.5
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
These finding suggest that health care providers need to recommend preventive screenings,
especially PAP and colonoscopy, to their older patients living in North Penn.
118
Health Behaviors
Smoking
Older adults in Abington's CB areas are less likely to be smokers than are older adults in Bucks/Mont
as a whole. The percentage of smokers in all areas is below the Healthy People 2020 target and lower
than the total population in each geography.
Age 60+ % Who Smoke
Healthy People 2020 Target = 12%
9.5
8.0
7.8
6.6
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Although North Penn/Indian Valley respondents age 60+ report the lowest rate of smoking, these
residents also report the highest rate of having a smoker inside the home. The deleterious effects of
second hand smoke are well documented.
% Age 60+ with Smoker Inside Home
9.0
7.1
6.4
3.2
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Smokers in Abington's CB areas were less likely to have tried to quit smoking compared to the
Healthy People 2020 goal. Physicians should refer patients to state and local free programs including
FAX to QUIT and the Pennsylvania QUIT line.
119
Age 60+ % Who Tried to Quit Smoking in Past Year
Healthy People 2020 Target = 80%
66.4
65.6
51.9
45.9
North Penn/ Indian William Tennent/
Valley
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Fewer than 5% of older adult respondents smoke e-cigarettes.
Age 60+ % Smoking e-cigarettes/Frequency of
Use in the Past Month
2.3
4.4
1.1
1.4
4.2
2.6
2.3
0.3
North Penn/ Indian William Tennent/
Eastern
Valley
Central Bucks
Montgomery
Once/ a few times
At least once per week
Bucks/Mont
Daily
PHMC Household Health Survey 2015
Physical Activity
Physical activity is important to healthy aging. It maintains muscle strength, bone density, and helps
to prevent weight gain and depression. Compared to other neighborhoods in Abington's CB area,
older adults in William Tennent/Central Bucks are more likely (26.9%) to be physically inactive
versus 20.6% in Bucks/Mont. In contrast, almost three quarters of Eastern Montgomery adults age
60+ report being physically active at least once a week.
120
100%
%Age 60+ Exercising > 30 Minutes: # Days/Week
90%
80%
37.3
46.0
39.8
43.0
33.6
26.0
70%
60%
50%
40%
30%
20%
10%
28.1
24.6
7.7
8.3
26.9
21.1
10.5
14.4
20.6
12.2
0%
North Penn/ Indian
William Tennent/
Eastern Montgomery
Bucks/Mont
Valley
Central Bucks
Never
Less than once a week
Once or twice a week
Three times a week or more
PHMC Household Health Survey 2015
As physical activity increases, so does falls risk. Residents of William Tennent/Central Bucks and
Eastern Montgomery reported falling nearly twice as much as seniors in North Penn/Indian Valley.
% Age 60+ Who Fell in Last Year
23.0
21.7
22.8
12.3
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Physical activity in Eastern Montgomery may correspond to being more comfortable visiting a park
or outdoor space during the day compared to the other Abington CB areas and Bucks/Mont.
121
% Age 60+ Comfortable Visiting a Park or
Outdoor Space During the Day
80.7
77.3
74.5
73.6
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Poverty and Dual Eligibility
In 2015, the poverty threshold for an individual was $11,770 and a family/household of two was
$15,930.98 In Bucks/Mont, the percentage of adults age 60+ living below 100% poverty is less than
the poverty rate for the total population (5.8%). However, as previously noted, poverty can result in
an increased risk of mortality, prevalence of medical conditions and disease incidence, depression,
intimate partner violence, and poor health behaviors, factors that are exacerbated in an older, more
vulnerable populations.
% Age 60+ Below 100% Federal Poverty
Guideline
4.9
4.3
3.0
2.5
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Some of these individuals live in deep poverty, with incomes below 50% of the federal poverty
guideline. Eastern Montgomery has a disproportionate share of people living in deep poverty.
122
% Age 60+ Below 50% Federal Poverty
Guideline
2.7
1.2
1.0
0.5
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
According to a 2014 report prepared by the Montgomery County Planning Commission,
Montgomery County estimated that 7,833 individuals age 65 and over are duel eligible for both
Medicare and Medicaid. This population has a higher incidence of cognitive impairment, mental
disorders, diabetes, pulmonary disease, and stroke. In addition to having lower incomes, they are
more vulnerable, frail, and isolated than non-dual eligible elderly. These problems contribute to
additional challenges with housing, food, and transportation. Sixty-one percent of this population
lives in the community, and the remainder are in nursing facilities.
The report outlined the following 9 recommendations to plan a better future for Montgomery
County's dual eligible elderly:
1.
2.
3.
4.
5.
6.
Pilot test managed long-term supports and services (MLTSS) program
Implement program of all-inclusive care for the elderly (PACE)
Explore "duel eligible specific" accountable care organization (ACO)
Develop and facilitate primary care medical homes (PCMHs)
Continue and expand primary care medical home severe mental illness integration program
Push supports and services into naturally occurring retirement communities (NORCs) "NORC PLUS supports and services" or "NORC as anchor for array of supports and services"
model
7. Add independence at home (IAH) to home and community-base services (HCBS) waiver
8. Offer dual eligible targeted case management
9. Enhance dual eligible care setting transitions 99
Nutrition and Food Access
Access to healthy affordable food can play a role in the overall health of seniors. Some barriers that
affect seniors related to having enough food are: inability to shop for oneself, lack of transportation,
other living expenses, lack of familial support, education of assistance programs, lack of affordable
groceries, dementia, specific food diets or recommendations from doctors, and daunting paperwork.
123
Almost all older adults in Abington's CB areas say the quality of groceries in their neighborhood is
excellent or good and almost half have at least 3 servings of fruits and/or vegetables each day.
100%
Age 60+ # Servings of Fruits & Vegetables per Day
10.9
9.3
39.7
36.0
48.0
53.3
80%
60%
18.6
14.3
28.8
31.7
51.1
51.8
40%
20%
0%
North Penn/ Indian William Tennent/
Eastern
Valley
Central Bucks
Montgomery
0
1 to 2
3 to 4
5 or more
Bucks/Mont
PHMC Household Health Survey 2015
It is important to note that a small percentage of the adults age 60+ in Abington's CB areas cut a meal
in the past month due to lack of money. This is a sign of food insecurity. Food insecure seniors are:




40% more likely to report an experience of CHF
53% more likely to report a heart attack
twice as likely to develop asthma
60% more likely to experience depression100
% Age 60+ Who Cut a Meal due to Lack of
Money
4.4
2.3
2.5
0.8
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
More than 90% of seniors in Abington CB areas were aware of a meal or food program, while 2% or
less needed a meal program in the past year. Although the numbers in need are relatively small, food
insecurity is a significant issue for this population. Furthermore, since people taking medicine often
need to take medicine with food, lack of food security may impede medication adherence.
124
8.8
% Age 60+ Unaware of Meal/Food
Programs
7.6
7.4
4.3
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
% Age 60+ Needed Meal Programs in Past
Year
2.0
1.7
1.0
North Penn/
Indian Valley
1.0
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Social Connectedness
Feeling connections to the community is important to prevent isolation and depression in seniors.
Social networks are protective factors for health and wellness. More than half of older adults in
Abington's CB areas currently participate in at least one organization and more than 1 in 8 participate
in 3 or more organizations. Abington's Muller Institute for Senior Health Eldermed initiative sponsors
social events for members as part of its free wellness program.
125
% Age 60+ Currently Participating in
Organizations
16.5
12.3
14.3
14.9
41.5
43.8
44.8
42.8
41.9
43.9
40.9
42.2
North Penn/
William Tennent/
Eastern
Bucks/Mont
Indian Valley
Central Bucks
Montgomery
No Organizations
1-2 Organizations
3+ Organizations
PHMC Household Health Survey 2015
Between 24% and 38% of older adults in Abington CB areas say they are caring for a family member
or friend. This may reflect a need for caregiver supports such as respite care. The Muller Institute for
Senior Health offers caregivers a resource room and support group.
% Age 60+ Providing Care to Family/Friend During
the Past Month
38.1
34.9
31.1
24.2
North Penn/
Indian Valley
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
PHMC Household Health Survey 2015
Seniors also stay connected by talking with friends and family on the telephone. Almost 6% of adults
in William Tennent/Central Bucks who do not talk with friends or family are at risk for social
isolation and the resulting health issues.
126
% Age 60+ Frequency of Talking with Friends or
Relatives on the Telephone
12.4
8.1
9.1
3.9
5.2
0.7
4.6
5.7
3.5
North Penn/
Indian Valley
11.1
William Tennent/
Eastern
Bucks/Mont
Central Bucks
Montgomery
Never
< once a week
Once a week
PHMC Household Health Survey 2015
Housing
In Abington CB areas, approximately 80% of adults age 60+ own their homes.
% Age 60+ Home Ownership
4.3
16.1
79.3
76.1
16.4
7.8
North Penn/ Indian William Tennent/
Valley
Central Bucks
Rent
Own
6.3
5.8
84.0
80.5
9.7
13.7
Eastern
Bucks/Mont
Montgomery
Other arrangement
PHMC Household Health Survey 2015
Some older adults in Abington CB areas are faced with home repairs that are not possible due to low
fixed incomes. For elders who want to age in place, remaining in their homes for as long as possible
is important emotionally and economically. Older homes often have stairs and are multiple
dwellings. Having a home on the first floor is often not possible. These barriers affect seniors’
ability to take care of basic needs and to participate fully in the community.
%Adults Age 60+ with Home that Need Repair
North Penn/
Indian Valley
Roof
4.0
Plumbing
7.1
Heating
1.9
W. Tennent/
Central
Bucks
9.8
2.7
4.7
127
Eastern
Montgomery
8.0
3.7
0.6
Bucks/
Mont
6.3
5.0
3.1
Between 21 and 30% of Abington CB area seniors report difficulty in affording housing costs.
% Age 60+ Reporting Difficulty Affording
Housing Costs in Past Year
24.5
North Penn/
Indian Valley
29.7
29.4
Eastern
Montgomery
Bucks/Mont
20.8
William Tennent/
Central Bucks
PHMC Household Health Survey 2015
In Bucks/Mont, one fifth of adults age 60+ plan on moving from their current home in less than 5
years: this rate varies among Abington CB areas.
% Age 60+ Desired Duration of Stay in Current Home
60.9
66.2
59.3
62.0
23.6
20.4
18.1
17.7
15.4
13.4
22.7
20.3
North Penn/ Indian William Tennent/
Eastern
Bucks/Mont
Valley
Central Bucks
Montgomery
< =5 Years
> 5 but <10 years
10+ years
PHMC Household Health Survey 2015
Older adults from William Tennent/Central Bucks and Eastern Montgomery say they are more likely
to move into affordable senior housing in the next 5 years, while almost none from North Penn/Indian
Valley plan on this type of move.
100%
% Age 60+ Likelihood to Move into Affordable
Senior Housing in Next 5 Years
50%
0%
North Penn/ William Tennent/
Eastern
Bucks/Mont
Indian Valley
Central Bucks
Montgomery
Very likely
Somewhat likely
Not very likely
Not at all likely
PHMC Household Health Survey 2015
128
Communications
The majority of adults age 60+ in Abington CB areas do not use social media.
% Age 60+ Not Using Social Media in the
Past 3 Months
63.0
63.4
61.7
William Tennent/
Central Bucks
Eastern
Montgomery
Bucks/Mont
52.7
North Penn/
Indian Valley
PHMC Household Health Survey 2015
Postal mail is the preferred format to receive health or social service information in this age group.
Email is also a desirable way to receive such information for almost 25% in Bucks/Mont. Social
media is not a preferred way for receipt of this type of information.
100%
Age 60+ Preferred Way to Receive Health or Social Service
Information
Other*
Television
90%
Newspapers
80%
70%
Social Media
**
Postal Mail
60%
50%
40%
Email
30%
* Other includes telephone,
text messaging, and other
20%
10%
0%
North Penn/
Indian Valley
William Tennent/
Eastern
Central Bucks
Montgomery
PHMC Household Health Survey 2015
129
Bucks/Mont
** such as Facebook or
Twitter
Issues and challenges, unmet needs and priorities identified by key informants and focus group
participants related to older adults included:



Well Elderly
o A senior center is needed. In lieu of a bricks and mortar facility, a virtual senior center
was developed through a grant with Visiting Nurses Association Community Services.
o Need more low income subsidized housing, especially for those over 60. Females
around 60 are falling through the cracks.
o There is not enough communication of what activities for seniors are available. While
social media is effective for younger populations, "grassroots" communication is
appropriate for older adults.
o Need chest pain awareness and education - awareness of heart disease as the leading
killer include "Know Your Numbers" and sudden cardiac death. Staff need to be able
to have time to educate and go into the community.
Safety
o Need to protect older adults against fraud
o Abuse and neglect, including financial, physical, emotional, affects seniors. Waiting
lists for protective services are long
o Trauma related to falls for seniors needs more attention
Care Coordination
o Pan Asian Senior Services (PASSi) does not offer skilled services
o Need more education regarding the medical system and financial assistance for older
immigrants and those who do not speak English well. Fear of going to doctor and fear
of outcomes/cost are related to cultural backgrounds. A community center to house
educational programs is needed.
o Seniors struggle with knowledge of where to go regarding available services
o Care is not available at all levels. Care managers and case managers are increasingly
integrating skilled nursing facility [SNF] care as a response to newer reimbursement
structures and changing health care delivery system issues.
o There is a lack of social responsibility towards family members which reflects issues
in the state of our community connectedness.
o Dehydration is a concern
o Discharged older adults lack follow up after returning home
o Seniors living alone and low income seniors cannot afford homecare assistance
o After discharge from homecare, there is lack availability of skilled in-home medical
oversight for the homebound elderly, increasing their risk of falls, frailty, and
medication mismanagement
o Post discharge from homecare, there is a lack of support for an informal continuum of
care
o Most older adults and their caregivers do not know the cost of the care and
medications associated with stroke
o Meeting the need for rehab in the weeks following discharge for stroke could be
improved
o After discharge from post acute services, stroke patients experience unresolved
disabilities, are unable to return to full function, and are homebound
130




End of Life care - Palliative Care and Hospice
o People are living longer and are spending their resources but worried about end of life
decision-making
Care Giver Stress
o "Caregivers can't always get out to do it all"
Transportation to offices and hospital
o Assess van use to reduce no shows at support groups and physician appointments.
Seniors can't take the bus and care givers can't always provide transport
o Seniors need financialsassistance for transportation needs
Food insecurity
o Barriers to healthy lifestyles include eating well
Recommendations included:
1) Communicate that Abington Hospital's cafeteria is open for meals and conversation to
those who need it, i.e., isolated seniors
2) Build networks of linked community services and agencies to benefit the elderly,
especially the "old old" living alone. Disseminate information about these services.
3) Need reasonable transportation services
4) Need a Lifecare or senior center
5) Support for care givers
6) Expand the Matter of Balance Program, an evidence-based fall reduction program
promoted by Healthy Montgomery.org
7) Provide fans or air conditioners to seniors, or those with chronic conditions
131
Immigrants and Refugees
There are multiple concerns regarding data on immigrants. Undocumented immigrants are likely to
be undercounted. Census data are presented as estimates and are subject to sampling error. When
analyzing smaller geographies, the margin of error increases. PHMC data is skewed due to sampling
bias. While Spanish language interviewers were available, no interviews were conducted in Asian (or
other) languages, biasing the results to include only people who spoke adequate English. Although
PHMC data was collected using land and cellular telephone interviews, there may be a small
population that does not have either. With these cautions, the following data is presented.
Immigrants
According to the US Census Bureau,101 of Bucks/Mont's total population of 1.4 million residents,
9.2% are foreign born. Of these, 92% entered the country before 2010, and 41% are not citizens. The
majority of immigrants coming to Bucks/Mont are from Asia (47%) and Europe (26.%).
Bucks/Mont Foreign Born Origin
2%
20%
26%
Europe
Asia
Africa
0%
5%
Oceania
Latin America
North America
47%
2010-2014 American Community Survey 5 year Estimates
Asian Indians and Koreans represent the largest Asian immigrant populations in Abington CB areas,
accounting for 57% of those with Asian heritage. North Penn has the highest number of Asians
including a Bangladeshi community.
Southeast Asians have been seen to differ significantly from more acculturated Asian ethnic groups,
especially in their immigration patterns. Unlike the more upwardly mobile East and South Asian
immigrants who immigrated to the U.S. for economic and social reasons, the vast majority of
132
Southeast Asians arrived in the U.S. as political refugees from Vietnam, Cambodia, and Laos
beginning in the 1970s. Many Southeast Asians were forced to leave their homes to preserve their
lives and escape persecution, leaving without preparation or knowledge of the country of their
settlement. Since then, the U.S. government has resettled many Southeast Asians in places where
they are culturally and linguistically isolated. In Abington CB areas, 11% (4,200 people) of the Asian
immigrant population are estimated to be from these countries. Cultural and linguistic differences
have created a number of structural and behavioral barriers to health care for these populations.
Asian Population Estimates, 2014
Abington CB
Area
Korean
Asian
Indian
Chinese ,
except
Taiwanese
Vietnamese
Filipino
Bangladeshi
Other
*
1,673
833
884
292
181
-
473
4,336
Central Bucks
512
981
856
108
225
-
81
2,763
Indian Valley
572
1,179
248
845
25
-
280
3,149
Lower Eastern
1,570
520
1,048
546
299
-
432
4,415
North Penn
3,460
4,984
1,707
1,150
1,119
1,001
802
14,223
Upper Dublin
2,697
1,210
2,032
274
281
-
224
6,718
Abington
William
456
996
364
249
231
340
Tennent
Grand Total
10,940
10,703
7,139
3,464
2,361
1,001
2,632
* Includes Cambodian, Indonesian, Japanese, Hmong, Laotian, Malaysian, Pakistani, Sri Lankan,
Taiwanese, Thai, Other Asian, and not specified
Total
2,636
38,240
Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates, Table B02006
Asian Alone by selected group
People from Puerto Rico account for the largest group of Hispanics living in Abington CB areas. As
American citizens, they do not face challenges related to legal status, and are free to move between
the mainland and their island. They reside throughout Abington CB areas.
Mexicans are more concentrated in William Tennent, where the highest number of Hispanic/Latinos
of all origins reside.
The populations from South and Central America originate from a wide variety of counties. Other
than Mexico, the population from any individual country is estimated to be less than a thousand in
Abington CB areas.
Hispanic or Latino Population Estimates, 2014
CB Area
Abington
Central Bucks
Indian Valley
Puerto
Rican
Mexican
South
American
Central
American
Dominican
Cuban
Other*
1,563
624
571
316
556
149
196
57
35
1
139
15
207
170
3,267
1,332
502
226
297
602
120
66
158
1,971
133
Total
Hispanic or Latino Population Estimates, 2014
Puerto
Rican
Mexican
South
American
Central
American
Dominican
Cuban
Other*
CB Area
Lower Eastern
1,139
482
834
130
318
149
204
3,256
North Penn
1,396
791
672
465
138
178
178
3,818
Upper Dublin
1,097
698
371
313
172
157
159
2,967
William Tennent
1,261
1,896
273
468
104
23
85
4,110
1,161
20,721
Grand Total
7,582
4,980
*Other includes Spanish and unspecified
3,152
2,231
888
727
Total
Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates, Table B03001 Hispanic or
Latino Origin by specific origin.
More than one quarter of residents of North Penn report speaking a language other than English at
home, a percentage much higher than other Abington CB areas and Bucks/Mont. In North Penn the
most frequently spoken foreign languages are Asian Indian (e.g. Hindi, Malayalam, Gujarati, Urdu,
Telugu)(20%), Italian (15%), Spanish (14%), and a Chinese language (11%). Other languages
present in Abington CB area homes include: Korean, Russian, Vietnamese, French, Polish, Yiddish,
and American Sign Language.
%Speaking a Language Other than English at Home
26.9
13.7
15.8
10.7
North Penn
Indian
Valley
William
Tennent
Central
Bucks
11.5
12.3
12.0
11.3
Lower
Eastern
Abington
Upper
Dublin
Bucks/
Mont
PHMC Household Health Survey 2015
134
According to PHMC data, non-Latino Asians and Latinos fare worse on many health status questions
when compared to the non-Latino whites who live in the same Bucks and Montgomery counties.
Fair/Poor health status
No health insurance
No prescription insurance
No regular source of care
No visits to healthcare provider in past year
Last visit to dentist > 2 years
Last PAP > 3 years
Last mammography> 2 years
Last sigmoidoscopy >10 years or never (age 60+)
Has diagnosed mental health condition
Ever had asthma
Ever had diabetes
Ever had high BP
Obese
Overweight
Total Obese/Overweight
Due to cost, went without:
Medical care
Prescription
Meal
%NonLatino
White
10.9
1.7
7.2
7.8
11.5
15.9
24.7
24.7
23.3
15.6
14.6
10.3
30.8
28.3
34.4
62.7
%NonLatino
Asian
5.2
3.4
2.7
13.8
17.2
26.5
25.5
27.2
29.8
4.9
15.8
5.3
22.0
6.4
32.9
39.3
%Latino
7.3
10.8
3.9
5.2
12.1
17.6
14.2
16.0
0
21.0
13.2
10.2
12.3
17.5
19.1
18.9
15.2
38.2
11.3
18.9
11.4
17.9
32.6
28.2
60.8
HP 2020
Goal %
0
5
7
19
26.9
30.5
PHMC Household Health Survey 2015
Furthermore, when the results of a 2007 Southeast Asian Mutual Assistance Associations Coalition,
Inc. (SEAMAAC) survey in Philadelphia were compared with results of the 2004 PHMC survey of
the Asian population, there were many discrepancies between the two. It is likely that similar
disparities continue in the 2015 PHMC survey results. In most cases, health status and access to care
were understated in the PHMC data compared to the SEAMAAC data. The SEAMAAC data shows
significantly higher rates of hypertension and mental health conditions, but also reported lower rates
of insurance coverage and less health care utilization. Access to healthcare services was not available
in respondent’s native language for 68% in the study and health resources in native languages was not
available for 76% of those surveyed. This provides challenges for those seeking health care and
disease self-management. Preventive health care practices may also be challenged as a result of
differing health paradigms related to health beliefs and medical practices. Health care providers may
lack the awareness and competency to address these differences. There is a general lack of
appropriate and accessible mental health services for the Southeast Asian population, and concepts of
mental health diagnosis and treatment may differ among population subgroups. Southeast Asians
clearly lack much-needed access to health care and experience diminished quality of health care
135
because of their socioeconomic status, lack of citizenship, and limited English proficiency. Improving
services such as those that address resettlement needs, insurance, and social service options are
needed to help these populations access health care services.
Many of the same issues apply to the Latino population. Abington does have written materials
available in Spanish and some Spanish speaking staff. Cultural competence, recognizing the variety
of Latino cultures, belief systems, and health conditions, is important in addressing the needs of this
diverse population.
Issues and challenges, unmet needs and priorities identified by key informants and focus group
participants related to immigrants and refugees included (repeated from other sections):

Communication
o Hospital staff lack cultural competency skills
o Language is a barrier for the Korean community, especially for education on diseases,
prevention, and health insurance issues

Culture
o Some immigrants from Mexico and Central America are afraid of going to doctor,
fearing outcomes and cost. Language and culture are barriers.
o Asian patients utilize the hospital system differently than other Abington CB area
residents. Asians use more clinics and ER visits verses primary care physician visits.
Interpretation
o There are no skilled home care agencies that provide bilingual services to the Korean
community. "Needs go beyond language issues alone."
o There are opportunities to improve our interpretation to English as a Second Language
patients.

Recommendations included (repeated from other sections):
1) Need more tailored education with trans-cultural consideration
2) Need more education regarding the medical system and available financial assistance for
immigrants; educational programs are planned for a future community center to house
such programs to serve the Latino population in and near Hatboro
3) Need more social workers bilingual in Korean who are knowledgeable about benefits,
especially for older Korean Americans
136
Homeless
The number of homeless individuals is counted at various points in time. On January 28, 2015 in
Montgomery County, there were 249 homeless members of households, all sleeping in shelters. On
August 27, 2015, the number increased to 411 individual members of households, with 28
unsheltered. There were also homeless individuals. The number of homeless people in winter census
declined 7% from 464 in 2013 to 430 in 2015. At the time of the 2015 winter homeless count, 25%
of the people were victims of domestic abuse, 39% were children under age 18, and 8% were
chronically homeless.102
The causes of homelessness and the characteristics of the homeless differ greatly across
subpopulations. In Montgomery County, the majority of people who are homeless or at risk of
homelessness are families with financial hardship. For a portion of the 8% who are chronically
homeless, their mental illness involves a personality disorder that makes them averse to being around
and living with other people. The street population is made up almost exclusively of single adults, as
emergency housing programs are utilized to a greater extent by families, especially single mothers
with children. Among those individuals are service-resistant chronically homeless people with serious
mental illness. While these people make up a relatively small proportion of the homeless population,
they are the most frequent and expensive users of the system. Characterized by serious mental illness,
substance abuse and personality disorder, this subset of the homeless population is adverse to being
around and living with other people. For people suffering from personality disorder as part of their
mental illness, living alone on the streets is preferable to being around other people, much less
abiding by a strict set of externally imposed rules. Understanding this aversion to be around other
people provides an opportunity to help them. Nationally, there is a move away from the Continuum
of Care approach to dealing with the service-resistant, seriously mentally ill homeless. This emphasis
has led to interest among practitioners in the Housing First approach to serving this population.
Montgomery County has also moved in this policy direction by supporting initiatives to move
individuals into permanent housing.
Launched in January 2014, Your Way Home (YWH) Montgomery County is a partnership between
government, philanthropy, and community organizations to end homelessness and housing instability
for families and vulnerable residents. By forging new networks, innovating, leveraging existing
community assets and planning for dramatic changes in federal policy and funding priorities, YWH
Montgomery County's ultimate goal is to end homelessness in the county and its 5 year goal is reduce
homelessness by 50%.103 An individual or family must be homeless to get YWH assistance. The
homeless live in shelters or on the streets, parks, in cars or garages, in tents or in shelters and the
majority of them are families. Finding stable and safe housing reduces depression, physical and
mental illness and child neglect.104
YWH Montgomery County reports the following successes in 2014:
 Shelters provided 690 families and individuals with a place to sleep in 2014. Exits directly to
permanent housing increased from 29% in 2013 to 41% in 2014.
 51% of YWH clients of uninsured patients were connected to health insurance by the time
they exited to permanent housing in 2014
 240 people with significant barriers to housing stability were placed in permanent housing in
2014
137

YWH helped 520 people end their housing crisis, a 200% increase from the previous year
Issues, challenges unmet needs and priorities identified by key informants and focus group
participants related to the homeless included:
o Homelessness affects all ages. The homeless are living in their cars in every town but
are not seen on the streets. Montgomery County has begun a blueprint for action
under the "Your Way Home" initiative. All information/support/case management is
being centralized at the county level and via non-profit organizations to one
communication point.
o Homeless outreach is expanding from Philadelphia into Abington.
o Shelters are at capacity; there are not enough beds in Montgomery County
o The wait list is long for subsidized housing. "Females around 60 are falling through
the cracks."
o Identifying the homeless and getting them to resources is a challenge
o The "housing system is broken in Montgomery County"
o Some low income housing is not adequately suited for underserved with chronic
illness, e.g. there are not always kitchens which influences nutritional intake; fans
could make a difference; some cannot pay for heat
Recommendations included:
1) Partner with community based organizations serving the homeless
2) Resources committed to getting people back to work are needed
3) Hospital personnel should work with collaborative partners and the county
departments will assist in facilitating access and coordination of already existing
services
138
Recommendations
To address the community health needs identified in the CHNA, recommendations for initiatives
were prioritized based on secondary data findings, primary data gathered through key informant
interviews, and the focus groups with community residents. Participants in key informant interviews
and focus groups were asked to identify the health needs of the community and were then asked to
identify those they felt were most important to address. They were also asked to recommend
potential initiatives to address these needs.
The identified priority health needs and recommended initiatives were then grouped into the
following domains:





Internal organizational structure
Access to care
Chronic disease management,
Health screening and early detection
Healthy lifestyle behaviors and community environment
To further prioritize these initiatives, a team of Community Benefit professionals developed thirteen
criteria with weighted values. Scoring could range from 0-3 depending on the assigned weighted
value. Community benefit professionals independently ranked each health need/issue using the
agreed upon criteria. Criteria scores were then summed for each identified health need/issue and the
totals were averaged using input from each scorer. The criteria and weighted values are provided
below:
Criteria
Does not meet HP 2020
Regional priority (SHIP priority for Southeastern Pennsylvania)
Disparity exists compared to Bucks/Mont
Focus groups and key informants perceive problem to be important
Sub-population is special risk
Problem not being addressed by other agencies
Has great potential to improve health status
Positive visibility for AJH
# people affected
Feasibility/resources available/existing relationships in place
Links to AJH strategic plan and/or service line plan
Sustainability
Collaboration opportunities
Maximum
Weighted
Value
2
3
3
2
3
1
3
1
3
2
2
2
2
The prioritization and rankings inform the implementation plan and the timeline for phasing in these
interventions. The list below summarizes the results of the prioritization process:
139
Domain
Priority Health Needs/Issue
Access to Care
Chronic Disease Management
Access to Care and
Community Environment
Healthy Lifestyle Behaviors
and Community Environment
Health Screening and Early
Detection
Chronic Disease Management
Health Screening and Early
Detection
Access to Care
Access to Care
Healthy Lifestyle Behaviors
and Community Environment
Access to Care
Access to Care
Access to Care
Healthy Lifestyle Behaviors
and Community Environment
Healthy Lifestyle Behaviors
and Community Environment
Access to Care
Healthy Lifestyle Behaviors
and Community Environment
Healthy Lifestyle Behaviors
and Community Environment
Internal Organizational
Structure
Healthy Lifestyle Behaviors
and Community Environment
Access to Care
Internal Organizational
Structure
Healthy Lifestyle Behaviors
and Community Environment
Health Screening and Early
Detection
Ranking
Score
Priority Level
Mental Health Services
Obesity
27.0
24.3
Most Important
Most Important
Social and Health Care Needs of Older
Adults
Alcohol/ Substance Abuse
24.3
Most Important
23.0
Most Important
Women's Cancer
23.0
Most Important
Chronic Disease Management (diabetes,
heart disease and hypertension, stroke,
asthma)
Colon Cancer
22.7
Most Important
21.7
Most Important
Health Education, Social Services and
Regular Source of Care
ED Utilization and Care Coordination
Youth Health Behaviors
21.0
Most Important
19.7
18.3
Important
Important
Health Insurance
18.3
Important
Medication Access
Language Access, Health Literacy and
Cultural Competence
Physical Activity
18.0
17.7
Important
Important
17.0
Important
Access to Healthy Affordable Food and
Nutrition Education
Maternal and Child Health
Smoking Cessation
16.0
Important
15.3
14.7
Important
Less Important
Food Security
14.7
Less Important
Hospital Readmissions
14.7
Less Important
Community Safety
14.3
Less Important
Access: Transportation
14.0
Less Important
Workforce Development and Diversity
14.0
Less Important
Built Environment
9.3
Less Important
HIV
8.3
Less Important
140
Working under the guidance of the Abington Health Foundation Community Benefit Committee
since 2011, the Community Health Department of Abington Jefferson Health is responsible for
developing CHNAs and resultant implementation plans focusing on priority issues. Eight Community
Benefit Action teams consisting of key community stakeholders and Abington Health administrative
and clinical leaders were formed in 2013 to develop and implement goals and action plans to address
the needs identified in the 2013 CHNA process. Leaders of these teams reported on progress
quarterly through reports shared with the Community Benefit Committee. Similar to the process
initiated in 2013, new teams and leaders will be identified and responsible for the development and
coordination of the 2016-2019 implementation plans subsequent to thorough review of the 2016
CHNA. The Community Benefit Committee will continue to monitor and guide the progress of the
implementation plans.
In addition, Abington Jefferson Health professionals will collaborate with Jefferson colleagues to
improve health status in conjunction with the hospital’s partnerships. Best practices will be shared
with the aim of enhancing infrastructure, stretching resources, and incorporating knowledge about
social determinants of health and health literacy to better the population's health and well-being.
141
Appendix A - Hospital Asset Listing
Hospitals- Bucks County
Name
Phone
Aria Health
Bucks County
Doylestown
Health
Grand View
Health
Lower Bucks
Hospital
St Mary
Medical Center
St. Luke's
Hospital
Quakertown
Address
City
Langhorne
19047
215-345-2200
380 N Oxford
Valley Road
595 West State St
Doylestown
18901
215-453-4000
700 Lawn Ave
Sellersville
18960
215-785-9200
501 Bath Road
Bristol
19007
215.710.2000
1201 NewtownLanghorne Rd
1021 Park Avenue
Langhorne
19047
Quakertown
18951
215-949-5000
215-538-4500
Zip
Website
https://www.ariahealth.org
/bucks-county
https://www.doylestownhe
alth.org/
https://www.gvh.org/
http://www.lowerbuckshos
p.com/
http://www.stmaryhealthc
are.org/
http://quakertown.slhn.org
/LocationsDirections/QuakertownCampus
Hospitals- Montgomery County
Abington
Hospital
Jefferson Health
Bryn Mawr
Hospital
Eagleville
Hospital
Einstein
Medical Center
Montgomery
Holy Redeemer
Health System
Lankenau
Hospital
AbingtonLansdale
Hospital
Jefferson Health
Mercy Suburban
Hospital
215-481-2000
1200 Old York
Road
Abington
19001
http://www.jefferson.edu/a
bington
484-337-3000
130 South Bryn
Mawr
100 Eagleville
Road
559 West
Germantown Pike
Bryn Mawr
19010
Eagleville
19403
East Norriton
19403
1648 Huntingdon
Pike
100 Lancaster Ave
Meadowbrook
19046
Wynnewood
19096
215-368-2100
100 Medical
Campus Dr
Lansdale
19446
http://www.mainlinehealth
.org/brynmawr
http://www.eaglevillehosp
ital.org/
http://www.einstein.edu/lo
cations/einstein-medicalcenter-montgomery/
http://www.holyredeemer.
com/Main/Home.aspx
http://www.mainlinehealth
.org/Lankenau
http://www.jefferson.edu/a
bington
610-278-2000
2701 DeKalb Pike
East Norriton
19401
MossRehab
Hospital
Pottstown
Memorial
Medical Center
215-663-6000
60 Township Line
Road
1600 East High
Street
Elkins Park
19027
Pottstown
19464
Valley Forge
Hospital
610-539-8500
1033 W
Germantown Pike
Norristown
19401
610-539-6000
484-622-1000
N/A
484-476-2000
610-327-7000
142
http://www.mercyhealth.or
g/locations/mercysuburban/
http://www.einstein.edu/lo
cations/mossrehab/
http://www.pottstownmem
orial.com/pottstownmemorial-medicalcenter/Home.aspx
http://www.vfmc.net/index
.html
Appendix B - Health Assets Listing
Health Assets- Bucks County
Address City
Zip Type
Code
Name
Phone
Aldie Counseling
Center
215-642-3230 2291 Cabot
Boulevard
Ann Silverman
Community Health
Clinic
BCHIP Children's
Dental Program
215-345-2260 595 W. State Doylestown 18901
Street
215-453-4382 700 Lawn
Ave
Langhorne 19047
Sellersville 18960
BCHIP Lower
215-633-8397 2546B
Bensalem 19020
Bucks Clinic
Knights Road
BCHIP Volunteer
215-529-7250 261
Quakertown 18951
Doctors Care Upper
California
Bucks
Road
Bethanna
215-355-6500 1030 Second Southampton 18966
Street Pike
Bristol Bensalem
Human Services
Center (NHS)
Bucks County
Health Department
Doylestown
610-260-4600 600 Louis
Drive
Warminster 18974
215-345-3318 1282
Almshouse
Road
Doylestown 18901
Bucks County
Health Department
Levittown
Bucks County
Health Department
Quakertown
Bucks County
Mental Health
Clinic
(215) 5473423
Levittown
215-529-7000 261
California
Road
215-788-5730 1270 New
Rodgers Rd
Quakertown 18951
Bucks County
Mental Health/
Development
Delaware Valley
Children's Center
215-773-9313 600 Louis
Drive
Warminster 18974
Delta Community
Supports Inc
Family Services
Association of
Bucks County
7321 New
Falls Road
Bristol
19055
19007
215-598-0223 2288 Second Newtown 18940
Street Pike,
Ste. 6
215-953-9255 720
Warminster 18974
Johnsville
Blvd
215-538-1616 515 S. West Quakertown 18951
End Blvd
143
Website
Mental Health/
http://www.aldie.org/
Substance Abuse
Center
Community Health http://aschealthclinic.org/
Center
Dental Care
http://www.bchip.org/incr
eased_access_to_dental_c
ar.html
Community Health http://bchip.org/bchip_adu
Center
lt_health_clinic.html
Community Health http://www.trivalleypc.co
Center
m/content/pdf/VolunteerDoctors-Care.pdf
Mental Health/
http://bethanna.org/
Substance Abuse
Center
Mental Health/
http://www.nhsonline.org/
Substance Abuse
Center
Health Department http://www.buckscounty.o
rg/government/healthservi
ces/HealthDepartment
Health Department http://www.buckscounty.o
rg/government/healthservi
ces/HealthDepartment
Health Department http://www.buckscounty.o
rg/government/healthservi
ces/HealthDepartment
Mental Health/
http://bucks.pa.networkofc
Substance Abuse are.org/mh/services/agenc
Center
y.aspx?pid=BucksCounty
MentalHealthClinic_361_
2_0
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
http://www.buckscounty.o
rg/government/humanserv
ices/MHDP
http://www.pmhccares.org
/bucks/
http://www.deltaweb.org/
http://www.fsabc.org/
Health Assets- Bucks County
Address City
Zip Type
Code
Name
Phone
Family Services
Association of
Bucks County
Family Services
Association of
Bucks County
Foundations
Behavioral Health
System
HealthLink Dental
Center
Ivyland Counseling
Center
215-345-0550 708 Shady
Retreat Rd
Doylestown 18901
215-757-6916 4 Cornerstone Langhorne 19047
Drive
215-345-0444 833 East
Butler
Avenue
215-364-4247 1775 Street
Road
215-444-9204 1210 Old
York Road
#202
215-345-2273 595 N West
Street
Doylestown 19801
Southampton 18966
Warminster 18974
Lenape Valley
Foundation Crisis
Center at
Doylestown Health
Libertae Halfway
215-639-8681 5245
House
Bensalem
Boulevard
Live Well Services 215-968-7600 203 Floral
Inc
Vale
Boulevard
Livengrin
215-638-5200 4833
Foundation
Hulmeville
Road
Maternal Child
267-525-7000 800 Clarmont
Consortium
Avenue
Warwick Family
Services
Mother Bachmann 215-245-4334 2546 Knights
Maternity Center
Road
Doylestown 18901
New Life of
Community Health
Services Inc.
New Vitae Inc
215-638-8600 3103
Hulmeville
Road
215-538-2424 16 South
Main Street
NHS Bucks County 215-752-5760 2260 W.
Cabot Blvd
No Longer Bound
Prevention and
Training Services
Website
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Community Health
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
http://www.fsabc.org/
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
http://www.libertae.org/
http://www.fsabc.org/
http://www.fbh.com/
http://www.healthlinkdent
al.org/
http://ivylandcounselingce
nter.com/
http://www.lenapevf.org/c
risis-services/centralbucks-crisis-services/
Bensalem
19020
Yardley
19067
Bensalem
19020
Bensalem
19020
Bensalem
19020
Women's Health
Center
http://www.stmaryhealthc
are.org/motherbachmann
maternitycenter
Bensalem
19020
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
http://livewellservicesinc.
com/contactus.aspx
Quakertown 18951
Langhorne 19047
215-788-9511 1230 Norton Bristol
Ave
144
19007
http://www.livewellservic
esinc.com/
https://www.livengrin.org/
http://www.warwickfamil
yservices.com/
http://newvitaewellness.co
m/
http://www.nhsonline.org/
http://www.uwbucks.org/r
esources/no-longerbound-prevention-andtraining-services/
Health Assets- Bucks County
Address City
Zip Type
Code
Name
Phone
Pan American
Mental Health
Services Inc.
215-788-6080 1 N. Wilson
Avenue
Bristol
19007
Mental Health/
Substance Abuse
Center
http://www.uwbucks.org/r
esources/pan-americanbehavioral-health-clinic/
Penn Foundation
Behavioral Health
Services
215-257-6551 807 Lawn
Avenue
Sellersville 18960
Mental Health/
Substance Abuse
Center
https://www.pennfoundati
on.org/servicesprograms/mental-healthservices/mental-healthservices.html
Penndel Mental
Health Center Inc
215-752-1541 1517 Durham Langhorne 19047
Road
http://www.penndelmhc.o
rg/
Project Transition
215-997-9959 1 Highland
Drive
Chalfont
Project Transition
215-491-2578 1700 Street
Road
Warrington 18976
Pyramid Healthcare 215-536-9070 2705 Old
Quarkertown (Teen
Bethlehem
Center)
Pike
Quakertown 18951
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Reach Intensive
Psychiatric
Rehabilitation
Sellersville 18960
Mental Health/
Substance Abuse
Center
Penndel
19047
Mental Health/
Substance Abuse
Center
http://rofbucks.com/
Bristol
19007
Mental Health/
Substance Abuse
Center
https://www.councilsepa.o
rg/locations/southernbucks-recoverycommunity-center/
19020
Community Health http://www.stmaryhealthc
Center
are.org/body.cfm?id=142
215-257-6551 712 Lawn
Avenue
Reach Out
215-970-5462 152 Monroe
Foundation of Bucks
Street
County: Dual
Diagnosis
Southern Bucks
215-788-3738 1286
Recovery
Veterans
Community Center
Highway
St. Mary Children's 215-245-8873 2546 Knights Bensalem
Health Center
Rd.
Today, Inc.
18914
215-860-1463 1990 North Langhorne 18940
Woodbourne
Road
Women's Recovery 215-289-6120 25 Beulah
New Britain 18901
Community Center
Road
145
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Website
http://www.projecttransiti
on.com/
http://www.projecttransiti
on.com/
https://www.pyramidhealt
hcarepa.com/locations/eas
ternpennsylvania/inpatientresidential-treatmentquakertown/
https://www.pennfoundati
on.org/servicesprograms/mental-healthservices/reach-intensivepsychiatricrehabilitation.html
http://todayinc.org/
https://www.councilsepa.o
rg/programs/pro-actwomens-recoverycommunity-center-andcentral-bucks-recoverysupport-services/
Health Assets- Montgomery County
Address City
Zip Type
Code
Name
Phone
Abington Family
Medicine of
Abington Jefferson
Health
Abington-Jefferson
Health Children's
Clinic
Abington-Jefferson
Health Physicians
Adult Health Center
with GwyneddMercy University
Ambulatory
Services of
Abington Jefferson
Health
Aldersgate Youth
Service Bureau
215-481-2725 500 Old York Jenkintown 19046
Road, Suite
108
Community Health http://www.jefferson.edu/
Center
abington
215-855-8296 51 Medical
Campus
Drive
215-481-6334 1200 Old
York Road
215-855-2899 51 Medical
Campus
Drive
215-481-2180 1200 Old
York Road
Lansdale
19446
Community Health http://www.jefferson.edu/
Center
abington
Abington
19046
Abington
19046
Community Health
Center
Community Health
Center
Abington
19046
Community Health http://www.jefferson.edu/
Center
abington
215-657-4545
Willow
Grove
19090
Mental
Health/Substance
Abuse Service
Corinne Santerian
Newborn Center of
Abington Jefferson
Health
Carson Valley
Children's Aid
Society
Central
Montgomery
MH/MR Center
Community Health
and Dental Care
Creative Health
Services
215-481-6605 1400 Old
York Road,
Suite D
Abington
19046
Community Health http://www.jefferson.edu/
Center
abington
610-326-9460 11 Robinson Pottstown
St
610-326-8712 11 Robinson Pottstown
St
19464
Dental Clinic of
Abington Jefferson
Health
Discovery House
215-481-2193 1200 Old
York Road
19046
42 N. York
Road
484-534-2989 1419
Flourtown 19031
Bethlehem
Pike
610-279-9270 1201 Dekalb Norristown 19401
Pike
Abington
215-657-8882 329 West
Hatboro
Country Line
Road
Financial Assistance 215-481-2185 1200 Old
Abington
Program of
York Road
Abington Jefferson
Health
Project Hope
610-630-2111 3125 Ridge Eagleville
Pike
Gaudenzia
610-239-9600 106 West
Norristown
Addicition
Main St
Treatment and
Recovery
146
Website
http://www.jefferson.edu/
abington
http://www.jefferson.edu/
abington
www.aldersgateservices.o
rg
Children and
Youth Services
www.cvca-pa.org
Mental Health/
Substance Abuse
Center
Community Health
Center
Mental Health/
Substance Abuse
Center
Community Health
Center
www.centralmhmr.org
Mental Health/
Substance Abuse
Center
Community
Service
www.discoveryhouse.com
19408
STD Clinic
19401
Mental Health/
Substance Abuse
Center
www.stdclinic.healthgrove.com
www.gaudenzia.org
19464
19040
19046
www.ch-dc.org
www.creativehs.org
http://www.jefferson.edu/
abington
http://www.jefferson.edu/
abington
Health Assets- Bucks County
Address City
Zip Type
Code
Name
Phone
HealthLink Dental
Clinic
Jaisohn Medical
Center
Jaisohn Medical
Center
Southampto 18966
n
Philadelphi 19126
a
Colmar
Community Health http://www.healthlinkdent
Center
al.org
Community Health http://jaisohn.com
Center
http://jaisohn.com
Lansdale
Mental Health
www.lifecounseling.org
Mental Health
Association
267-507-3510 536 DeKalb
Street
Norristown 19401
Mental Health
Association of
Southeastern
Pennsylvania
Montgomery
County Health
Department
Communicable
Disease Clinic
(Willow Grove
Health Center )
Montgomery
County Health
Department
Communicable
Disease Clinic
(Norristown Health
Center)
Montgomery
County Mental
Health
Montgomery
County Mental
Health
Montgomery
County Methadone
Center
NAMI
(215) 7511800
Philadelphia 19107
Mental
Health/Substance
Abuse Service
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
www.livengrin.org
Mental Health
Association
215-364-4247 1775 Street
Road
215-224-2000 6705 Old
York Road
215-997-2101 2506 N.
Broad Street,
Suite 202
1-800-8821170 E.
2799
Main Street
215-540-8301 550
Pinetown
Road
267-507-3490 700 E. Main
Street
Life Counseling
Services
Livengrin
1211
Chestnut St
215-784-5415 102 York
Road, Suite
401
19446
Ft.
19034
Washington
Norristown 19401
Willow
Grove
Website
www.mhasp.org
www.mhasp.org
http://www.mhasp.org/
19090
Community Health http://www.jefferson.edu/
Center
abington
610-278-5145 1430 DeKalb Norristown 19401
Street
Community Health http://www.jefferson.edu/
Center
abington
610-272-1899 1430 DeKalb Norristown 19401
Street
Mental Health/
Substance Abuse
Center
Mental Health
Crisis Team
www.montcopa.org
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
www.rhd.org
610-279-6100 50 Beech
Drive
Norristown 19401
610-272-3710 316 DeKalb
Street
Norristown 19401
(215) 3617784
100 W. Main Lansdale
St
147
19446
www.mces.org
http://www.nami.org/
Health Assets- Bucks County
Address City
Zip Type
Code
Name
Phone
Norristown Public
Health Center
610-278-5145 1430 DeKalb Norristown 19401
Street
Norristown
610-278-7787 1401 DeKalb
Regional Health
St
Center
North Hills Health 215-572-0302 212 Girard
Center of Abignton
Ave
Jefferson Health
Northwestern
215-362-7955 200 N.
Human Services
Chestnut
Street
Northwestern
888-647-0020 2506 N Broad
Human Services
Street
Norristown 19401
Northwestern
Human Services
Community Health
Center (STD, HIV,
IMMUN, TB)
Community Health
Center
Website
www.pamontgomeryco.civicplus.c
om
www.dvch.org
Glenside
19038
Community Health www.jefferson.edu/abingt
Center
on
Lansdale
19446
Colmar
18915
888-647-0020 620 E
Germantown
Pike
Nurse Family
610-278-5117 1430 DeKalb
Partnership
Street
OB/GYN Center of 215-481-6784 1200 Old
Abington Jefferson
York Road
Health
Personal Navigator 1-800-5911421
Program of Visiting 8234
Highland
Nurses Association
Avenue
Community
Services [VNACS]
Planned Parenthood 610-279-6095 1221 Powell
Norristown
Street
Lafayette
Hill
19444
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Mental Health/
Substance Abuse
Center
Maternal and Early
Childhood
OB/GYN Care
Norristown 19401
www.plannedparenthood.
org
Planned Parenthood 610-326-8080 2081 High
Pottstown
Street
Pottstown
www.plannedparenthood.
org
Pottstown Public
Health Center
610-970-5040 364 King
Street
Pottstown
Resources for
Human
Development
Salisbury
Behavioral Health
6109-278-0700 901 DeKalb
Street
Spring-Ford Drug
and Alcohol
Counseling
Valley Forge
Medical Center
Outpatient
VNA Community
Services
Norristown 19401
Abington
19046
Abington
19001
www.nhsonline.org
www.nhsonline.org
www.nursefamilypartners
hip.org
http://www.jefferson.edu/
abington
Community Health http://www.vnacs.org/inde
Center
x.php?page=personalnavigator-program
Reproductive
Health/Sex
Education
19464 Reproductive
Health/Sex
Education
19464 Community Health
Center
Norristown 19401 Mental Health/
Substance Abuse
Center
215-884-5566 614 N.
Glenside
19038 Mental Health/
Easton Rd
Substance Abuse
Center
610-948-0393 201 N Fourth Royersford 19468 Mental Health/
Avenue
Substance Abuse
Center
610-539-8500 1033 W.
Norristown 19401 Mental Health/
Germantown
Substance Abuse
Pike
Center
215-572-7880 1421
Abington 19001 Visiting Nurse,
Highland Ave
Social Service
148
www.nhsonline.org
www.pamontgomeryco.civicplus.
com
www.rhd.org
www.salisb.com
www.springfordcounselin
g.org
www.vfmc.net
www.vnacs.org
Name
Phone
VNA Community
Services
VNA Foundation of
Greater North Penn
Willow Grove
Public Health Center
610-272-3373
Health Assets- Bucks County
Address City
Zip Type
Code
1109 DeKalb Norristown 19401 Visiting Nurse,
Street
Social Service
(215) 847P.O Box 867 Lansdale
19446 Visiting Nurse,
4401
Social Service
215-784-5415 102 York
Willow
19090 Community Health
Road
Grove
Center
149
Website
www.vnacs.org
http://www.npvnafoundat
ion.org/
www.pamontgomeryco.civicplus.
com
Appendix C - Social Assets Listing
Social Assets- Bucks County
Zip
Address
City
Code
Type
Website
800- 810-4434
1909 Veteran's
Highway
Levittown
19056
Homeless
Shelter
http://www.uwbucks.or
g/resources/buckscounty-emergencyhomeless-shelter/
BARC
Developmental
Services
Benjamin H.
Wilson Senior
Center
Bensalem Senior
Citizens Center
Bensalem WIC
Clinic
Boy Scouts of
America
(Washington
Crossing
Council)
Bristol Bensalem
Human Services
Center (NHS)
215-794-0800
4950 York
Road
Holicong
18928
Disability
Services
215-672-8380
580 Delmont
Ave
Warminster
18974
Senior
Services
http://www.barcprogra
ms.org/PublicPages/Ho
me.aspx
http://www.wilsonsenio
rcenter.com/
215-638-7720
Bensalem
19020
Bensalem
19020
Senior
Services
WIC
215-348-7205
1850 Byberry
Road
2546 Knights
Road
1 Scout Way
Doylestown
18901
Youth
Services
610-260-4600
600 Louis Drive
Warminster
18974
http://www.nhsonline.o
rg/
Bristol Borough
Active Adult
Center
Bristol Township
Senior Center
Bucks County
Children and
Youth Social
Services Agency
Bucks County
Homeless Shelter
215-788-9238
Wood and
Mulberry
Streets
2501 Bath Road
Bristol
19007
Mental
Health/
Substance
Abuse
Center
Senior
Services
Bristol
19007
215-348-6900
4259 West
Swamp Rd
Doylestown
18902
Senior
Services
Social
Services
215-949-1727
7301 New Falls
Road
Levittown
19055
Homeless
Shelter
Bucks County
Housing Group,
Inc.
215-598-3566
2324 Second
Street Pike
Wrightstown
18940
Social
Services
Central Bucks
Family YMCA
Center
Central Bucks
Senior Center
215-348-8131
2500 Lower St
Road
Doylestown
18901
YMCA/Y
WCA
http://www.theyoungin
heart.com/
http://www.buckscount
y.org/LivingAndWorki
ng/Services/ChildAbus
e
http://www.buckscount
y.org/livingandworking
/services/homelessshelters
http://www.buckscount
y.org/livingandworking
/services/homelessshelters
http://www.cbfymca.or
g/
215-348-0565
700 Shady
Retreat Rd
Doylestown
18901
Senior
Services
Name
Phone
American Red
Cross Lower
Bucks County
Homeless Shelter
215-244-2674
215-785-6322
150
N/A
https://www.pawic.com
/
http://www.washington
crossingbsa.org/
N/A
http://www.uwbucks.or
g/resources/centralbucks-senior-activitycenter/
Social Assets- Bucks County
Zip
Address
City
Code
Type
Website
Name
Phone
Chandler Hall
Health Services,
Inc.
Child Home &
Community
Community
Options
Doylestown WIC
Clinic
215-860-4000
99 Barclay
Street
Newtown
18940
Senior
Services
http://ch.kendal.org/
215-348-9770
Doylestown
18901
Langhorne
19047
http://chcinfo.org/index
.php
http://www.comop.org/
Doylestown
18901
Social
Services
Disability
Services
WIC
Eastern Upper
Bucks Seniors,
Inc.
610-647-8178
204 N. West
Street #101
340 E. Maple
Avenue #102
1282
Almshouse
Road
8040 Easton
Road
Ottsville
18942
Senior
Services
Falls Township
Senior Center
St. Mary Family
Resource Center
215-547-6563
282 Trenton
Road
2546 Knights
Road
Fairless
Hills
Bensalem
19030
Senior
Services
Social
Services
Levittown WIC
Clinic
Lower Bucks/
Fairless Hills
Family YMCA
Middletown
Senior Citizens
Center
Morrisville
Senior Service
Center
Morrisville
YMCA Child
Care
Neshaminy
Activity Center
Northampton
Township Senior
Center
215-580-3570
7321 New Falls
Road
601 S. Oxford
Valley Rd
Levittown
19055
WIC
Fairless
Hills
19030
YMCA/Y
WCA
215-945-2920
2142 Trenton
Rd
Levittown
19056
Senior
Services
https://www.facebook.c
om/Eastern-UpperBucks-Seniors-Inc172654929525424/
http://www.fallstwpseni
orcenter.org/
http://www.stmaryhealt
hcare.org/body.cfm?id=
143
https://www.pawic.com
/local.php?cid=107
http://lbfymca.org/locat
ions/fairless-hillsbranch
N/A
215-295-0567
31 E. Cleveland
Ave
Morrisville
19067
Senior
Services
215-736-8077
200 N.
Pennsylvania
Avenue
1842
Brownsville Rd
165 Township
Road
Morrisville
19067
YMCA/Y
WCA
Trevose
19053
Richboro
18954
Senior
Services
Senior
Services
Pennridge
Community
Center
Quakertown WIC
Clinic
215-453-7027
146 E. Main
Street
Perkasie
18944
Senior
Services
215-529-7482
261 California
Road
Quakertown
18951
WIC
Shared Support
Inc.
The Salvation
Army
267-247-5833
258 W. Ashland
Street
215 Appletree
Drive
Doylestown
18901
Levittown
19058
Disability
Services
Social
Services
215-752-3729
215-345-3494
215-245-8563
215-949-3400
215-355-6967
215-356-8199
215-945-0717
151
19020
N/A
http://www.morrisvilles
eniorservicenter.org/Ho
me.html
http://www.lbfymca.org
/locations/morrisvillebranch
http://neshaminyac.org/
http://www.northampto
ntownship.com/departm
ents/senior-centerservices.aspx
http://www.pennridgece
nter.org/
http://www.womeninfa
ntschildrenoffice.com/q
uakertown-wic-clinicwc4038
http://www.sharedsupp
ort.org/
http://pa.salvationarmy.
org/levittown
Social Assets- Bucks County
Zip
Address
City
Code
Type
Website
http://www.lbfymca.org
/locations/fairless-hillsbranch
http://lbfymca.org/locat
ions/tri-hamptonnewtown-branch
Name
Phone
The Wellness
Center at Fairless
Hills YMCA
Tri-Hampton
YMCA
(Newtown
YMCA)
Upper Bucks
County YMCA
Upper Bucks
Senior Citizen
Center
Valley Youth
House
Warminister
WIC Clinic
215-949-3400
555 S. Oxford
Valley Road
Fairless
Hills
19030
YMCA/Y
WCA
215-579-6200
190 S.
Sycamore St
Newtown
18940
YMCA/Y
WCA
215-536-8841
401 Fairview
Ave
2183 Milford
Square Pike
Quakertown
18951
Quakertown
18951
YMCA/Y
WCA
Senior
Services
http://www.ubymca.org
/
N/A
215-442-9760
800 N. York Rd
Warminster
18974
215-442-1099
605 Louis
Drive, Suite
508B
Warminster
18974
Homeless
Shelter
WIC
Wellspring
Clubhouse
215-257-4760
700 S. Main
Street
Sellersville
18960
http://www.valleyyouth
house.org/
http://www.womeninfa
ntschildrenoffice.com/
warminster-wic-clinicwc4052
http://www.paclubhous
e.org/WellspringClubho
use.php
Woods Services
Inc.
YWCA Bucks
Landing Family
Center
YWCA Bucks
Meadow Family
Center
YWCA Country
Commons
Family Center
YWCA
Creekside Family
Center
YWCA Glen
Hollow
Community
Room
YWCA Program
Outreach Center
215-750-4000
40 Martin Gross
Dr
120 E. Street
Road, Apt. L42, L4-4
3131 Knights
Road, Apt. 6-20
Langhorne
19047
Warminster
18974
Bensalem
19020
Social
Services
215-639-5853
3338 Richlieu
Road
Bensalem
19020
Social
Services
215-639-9550
2500 Knights
Road, Apt. 16001, 02
1100
Newportville
Road
Bensalem
19020
Social
Services
Croydon
19021
YMCA/Y
WCA
2425 Trevose
Road
Trevose
19053
YMCA/Y
WCA
215-536-3066
215-672-2974
215-633-1768
N/A
215-953-7793
152
Education
al/
Employm
ent Center
Disability
Services
Social
Services
http://www.woods.org/
http://www.uwbucks.or
g/resources/ywca-ofbucks-county/
http://www.uwbucks.or
g/resources/ywca-ofbucks-county/
http://www.uwbucks.or
g/resources/ywca-ofbucks-county/
http://www.uwbucks.or
g/resources/ywca-ofbucks-county/
http://www.ywca.org/si
te/pp.asp?c=gwKUJbN
YJxF&b=991971
http://www.ywca.org/si
te/pp.asp?c=gwKUJbN
YJxF&b=991971
Name
Phone
Social Assets- Montgomery County
Zip
Address
City
Type
Website
http://www.wicprogr
ams.org/li/pa_19001_
wic-office-abington
https://philaymca.org/
locations/abington/
http://www.alongthe
waypa.org/#alongthe-way
https://philaymca.org/
locations/ambler/
http://www.carie.org/
Code
Abington WIC
Nutrition Center
(215) 887-8006
1128 Old York
Road
Abington
19001
WIC
Abington YMCA
(215) 884-9622
Abington
19001
Along The Way Inc
(267) 382-9607
1073 Old York
Road
P.O Box 711
Souderton
18964
YMCA/
YWCA
Social
Services
Ambler YMCA
(215) 628-9950
Ambler
19002
CARIE
(215) 545-5728
1325 McKean
Road
1500 JFK Blvd
Philadelphia
19102
Cradle of Hope
(215) 572-5937
2238 Mount
Carmel Ave
Glenside
19038
Eldernet
(610) 525-0706
Bryn Mawr
19010
Encore Experiences at
Harleysville
(215) 256-6900
9 S. Bryn Mawr
Avenue
312 Alumni
Ave
Harleysville
19438
Family Services of
Montgomery County
Generations of Indian
Valley
(610) 630-2111
3125 Ridge
Pike
259 North
Second St
Eagleville
19403
Souderton
18964
Hatboro YMCA
(215) 674-4545
440 S. York Rd
Hatboro
19040
Home Helpers
(215) 631-9126
213 N. Broad St
Lansdale
19446
Inter-faith Housing
Alliance
(215) 628-2334
Ambler
19002
Interfaith Hospitality
Network
(610)277-0977
31 South
Spring Garden
S
1449 Dekalb St
Norristown
19002
Indian Creek
Foundation
(267) 203-1500
420 Cowpath
Rd
Souderton
18963
Keystone Opportunity
Center
Lansdale WIC Clinic
(215)723-5430
104 N. Main St
Souderton
18964
(215) 368-9826
607 North
Broad St
Lansdale
19446
Mental Health
Association: Halfway
There
(267) 507-3510
538 DeKalb
Street
Norristown
19401
(215) 723-5841
153
YMCA/
YWCA
Senior
Services
Homeless
Services
Senior
Services
Senior
Services
Social
Services
Commu
nity
Center
YMCA/
YWCA
Senior
Services
Homeless
Services
Homeless
Services
Disabili
ty
Services
Social
Services
WIC
Homeless
Services
http://cradleofhope.ne
t/
http://www.elderneto
nline.org/
http://www.ghnpss.or
g/encore_experience/
home
http://fsmontco.org/
http://generationsofiv
.org/
https://philaymca.org/
locations/hatboro/
http://local.homehelp
ershomecare.com/buc
ks/home/
http://www.i-fha.org/
http://philashelter.org
/
https://www.indcreek
.org/
http://keystoneopport
unity.org/
http://www.fns.usda.
gov/wic/womeninfants-and-childrenwic
http://montgomery.pa
.networkofcare.org/m
h/services/agency.asp
x?pid=MentalHealth
AssociationHalfwayT
here_801_2_0
Name
Phone
Social Assets- Montgomery County
Zip
Address
City
Type
Website
http://www.mfhs.org/
montgomery-countylocations/
http://montcosaac.co
m/
http://montcosaac.co
m/
http://www.montcopa
.org/index.aspx?nid=
148
http://www.mcab.org
/
Code
MFHS Norristown
(610) 272-4042
1340 DeKalb
Pike, Suite 1
Norristown
19401
WIC
MONTCO SAAC
(215) 619-8863
45 Forest Ave
Ambler
19002
MONTCO SAAC
(610) 275-1960
536 George St
Norristown
19401
Montgomery Co
Aging and Adult
Services
Montgomery Co.
Association for the
Blind
Montgomery Co.
Catholic Social
Services
Montgomery Co.
Youth Center
(610) 278-3769
1430 Dekalb
Center
Norristown
19404
Senior
Services
Senior
Services
Social
Services
(215) 661-9800
25 E. Marshall
St
Norristown
19401
(610) 279-7372
353 East
Johnston
Highway
540/550 Port
Indian Rd.
Norristown
19401
Norristown
19403
Morning Star
Maternity Home
(215) 723-8103
526 E Broad St
Souderton
18964
North Penn YMCA
(215) 796-5206
Colmar
18915
Office of Vocational
Rehabilitation
(484) 250-4340
2506 N. Broad
Street, Suite
208
1875 New Hope
St
Norristown
Peaceful Living
(610) 287-1200
569 Yoder Rd
Penn Asian Senior
Services
Peter Becker
Community Center
Positive Aging in
Lower Merion
(PALM)
Pottstown Area
Seniors' Center
Pottstown WIC Clinic
(215) 572-1234
Project Haven
(610) 631-1893
Disabili
ty
Services
Social
Services
http://cssphiladelphia.
org/
Youth
Detenti
on
Center
Pregnan
cy
Crisis
Center
YMCA/
YWCA
http://www.montcopa
.org/index.aspx?nid=
508
19401
Educati
on/Emp
loyment
Center
Harleysville
19438
6926 Old York
Rd
800 Maple Ave
Philadelphia
19126
Harleysville
19438
(610) 642-9730
117 Ardmore
Ave
Ardmore
19003
Disabili
ty
Services
Senior
Services
Senior
Services
Senior
Services
http://montgomery.pa
.networkofcare.org/m
h/services/agency.asp
x?pid=OfficeofVocat
ionalRehabilitation_8
01_2_0
http://www.peacefulli
ving.org/
(610) 323-5305
Pottstown
19464
(610) 232-8160
724 North
Adams St
262 King St
Pottstown
19464
(267) 281-4768
104 Main St
East
Greenville
18041
(215) 256-9501
154
Senior
Services
WIC
Youth
Services
http://www.mornings
tarmaternityhome.org
/
http://www.northpen
nymca.org/
http://passi.us/
http://peterbeckercom
munity.com/
http://www.palmseni
ors.org/
http://www.greaterpa
sc.com/
http://www.wicprogr
ams.org/li/pa_19464_
wic-office-pottstown
http://www.theproject
haven.org/projects.ht
ml
Name
Phone
Social Assets- Montgomery County
Zip
Address
City
Type
Website
Homeless
Services
Other
http://www.rhd.org/P
rogram.aspx?pid=37
Code
Resources for Human
Development CHOC
(610) 292-9244
1001
Stanbridge
Norristown
19401
RSVP
(610)834-1040
Blue Bell
19422
Salem Adult Citizens
(215) 884-7664
Gwynedd
Valley
Norristown
19437
Salvation Army
(610) 326-1621
925 Harvest
Drive
610 Summit
Ave
137 King St
The Giving Tree
(215) 872-9328
P.O Box 823
The Hospitality
Center
(610) 277-1321
530 Church St
The Ministries at
Main Street
(610) 970-2444
256 South
Hanover Street
Pottstown
19456
The Peak Center
(215) 362-7432
Lansdale
19446
Upper Main Line
YMCA
Upper Perkiomen
Senior Center
Variety- The
Children's Charity
(610) 647-9622
Berwyn
19312
(215) 679-6550
1292 Allentown
Rd. Suite A
1416 Berwyn
Paoli Rd
517 Jefferson St
East
Greenville
18041
(215) 735-0803
100 N. 18th St
Philadelphia
19103
Veterans Community
Network
(215) 527-6203
137 E. Woods
Dr
Harleysville
19438
Victim Services
Center
Youth Center Shelter
(610) 277-0932
325 Swede St
Norristown
19491
(610) 631-1893
550 Port Indian
Road
Norristown
19403
YWCA Tri-County
(610) 323-1888
315 King St
Pottstown
19464
19046
Jenkintown
Pottstown
155
19464
19401
Senior
Services
Social
Services
Social
Services
Homele
ss
Services
Homeless
Services
Senior
Services
YMCA/
YWCA
Senior
Services
Disabili
ty
Services
Social
Services
Social
Services
Homeless
Services
YMCA/
YWCA
http://www.rsvpmc.o
rg/
http://sbcoj.com/adult
Citizens.aspx
http://pendel.salvatio
narmy.org/easternpa/
pottstown
http://givingtreefamil
ies.org/
http://www.hospitalit
ycenter.org/
http://ministriesatmai
nstreet.org/
http://www.ghnpss.or
g/peak_center/home
https://www.ymcagb
w.org/
http://www.theopenli
nk.org/
http://varietyphila.org
/
http://www.veteransc
ommunitynetwork.co
m/
http://www.victimser
vicescenter.org/
http://www.montcopa
.org/index.aspx?nid=
508
http://www.ywcatrico
untyarea.org/
Appendix D - Food Assets Listing
Food Assets- Bucks County
Name
Phone
Address
City
Newtown
Zip
Code
Type
Active Acres Farms
215-860-6855
429 Stoopville
Rd
18940 Farmers
Market/
Produce
Stand
19007 Farmers
Market/
Produce
Stand
18944 Farmers
Market/
Produce
Stand
18962 Farmers
Market/
Produce
Stand
19007 Farmers
Market/
Produce
Stand
19007 Food
Pantry
Amish Bristol Market
215-826-9971
498 Green Lane Bristol
Bedminster Orchard
215-795-0303
1024 Kellers
Church Road
Perkasie
Bolton Farm Market
215-257-6047
1005 Main
Street
Silverdale
Bristol Amish Market
LLC
215-826-9971
498 Green Lane Bristol
Bristol Borough
Community Action
Group, Inc.
215-785-3296
99 Wood Street Bristol
Brumbaugh's Farm
215-723-3508
2575 County
Line Road
Cares Cupboard
215-750-7651
Charlann Farms
215-493-1831
152 Monroe
Street
586 Stony Hill
Rd
Coordinating Council of
Health and Welfare
215-672-9422
73 Downey
Drive
Country Commons
Family Center Food
Pantry
215-639-5853
3338 Richlieu
Rd
Bensalem
19020 Food
Pantry
Deep Well Farm
215-679-0206
1400 Fennel
Road
Pennsburg
18073 Farmers
Market/
Produce
Stand
Telford
18969 Farmers
Market/
Produce
Stand
Penndel
19047 Food
Pantry
Yardley
19067 Farmers
Market/
Produce
Stand
Warminster 18974 Food
Pantry
156
Website
www.activeacresfarm.
com
http://www.bristolami
shmarket.com/
https://www.facebook
.com/BedminsterOrchard199296833464631/
http://boltonfarmmark
et.com/
http://www.bristolami
shmarket.com/
http://www.foodpantri
es.org/li/bristolborough-communityaction-group-inc
http://www.brumbaug
hsfarm.com/
N/A
http://www.charlannf
arms.com/
http://www.foodpantri
es.org/li/coordinatingcouncil-of-health-andwelfare-emergencyfood-cupboard
http://www.foodpantri
es.org/li/ywca-ofbucks-countycountry-commonsfamily-center-foodpantry
http://agmap.psu.edu/
Businesses/index.cfm
?fid=6613
Food Assets- Bucks County
Name
Phone
Deere Acres
215-536-8859
Doylestown FM
215-345-5355
Doylestown Food Pantry 215-345-4311
Address
City
Zip
Code
Type
Website
2165
Quakertown 18951 Farmers
Trumbauersville
Market/
Road
Produce
Stand
West State
Doylestown 18901 Farmers
Street &
Market/
Hamilton Aven
Produce
Stand
470 Old Dublin Doylestown 18901 Food
Pike
Pantry
1085 Durham
Pineville
18946 Farmers
Road
Market/
Produce
Stand
8525 New Falls Levittown
19054 Food
Road
Pantry
http://agmap.psu.edu/
Businesses/index.cfm
?fid=3893
Fairless Hills 19030 Farmers
Market/
Produce
Stand
Langhorne 19047 Food
Pantry
http://fhproduce.com/
http://www.foodpantri
es.org/li/greaterworks-food-pantry
https://pa211.commun
ityos.org/zf/profile/ser
vice/id/1578694
http://www.hellericks
farm.com/
Eastburn Farm
215-598-3396
Emergency Relief
Association of Lower
Bucks County
Fairless Hills Produce
Center
215-547-1676
215-428-2420
636 Lincoln
Highway
Family Service
Association of Bucks
County
Greater Works Food
Pantry
215-757-6916
4 Cornerstone
Dr.
215-741-0525
Heaven's Bounty
215-536-1317
Hellerick's Family Farm
215-766-8388
Indian Valley Farmer's
Market
215-723-6627
Jesus Focus Ministry
215-953-2000
5918
Bensalem
19020 Food
Hulmeville
Pantry
Road
455
Quakertown 18951 Food
Trumbauersville
Pantry
Road
5500 Easton
Doylestown 18902 Farmers
Road
Market/
Produce
Stand
Main Street and Telford
18969 Farmers
Penn Avenue
Market/
Produce
Stand
1150 Bristol
Southampton 18966 Food
Road
Pantry
Langhorne FM
215-436-7448
E Richardson
Ave
Langhorne
Lapinski Farm
215-249-3431
1003 Middle
Road
Dublin
Loaves and Fishes Pantry 215-946-5800
840 Trenton
19047 Farmers
Market/
Produce
Stand
18917 Farmers
Market/
Produce
Stand
Fairless Hills 19030 Food
157
http://doylestownfarm
ersmarket.com/
http://www.bchg.org/f
ood-pantries/
http://www.eastburnp
umpkins.com/
http://www.ucclevitto
wn.org/#!era/cfi3
http://www.fsabc.org/
http://www.stmainst.o
rg/#!farmersmarket/c1fzx
https://www.facebook
.com/jfmpantry?rf=11
1665482197957
https://www.facebook
.com/LanghorneBorough-FarmersMarket525475107572780/
N/A
N/A
Food Assets- Bucks County
Name
Phone
Manoff Market Gardens
215-297-8220
Mary's Cupboard
215-949-1991
Maximucks Farm Market 215-297-9894
McArdle's Holiday Farm 215-794-7655
Milford Square Shelter
215-538-9383
Milk House Farm Market 215-852-4305
Morrisville Presbyterian
Church
215-295-4191
Myerov Family Farm
215-249-3145
New Britain Baptist
Church Food Larder
215-345-9170
New Hope FM
N/A
No Longer Bound Bristol 215-788-9511
Address
City
Road
3157 Comfort
Road
Solebury
Zip
Code
Type
Pantry
18963 Farmers
Market/
Produce
Stand
100 Levittown Levittown
19054 Food
Parkway
Pantry
5793 Long Lane Doylestown 18902 Farmers
Market/
Produce
Stand
4316
Mechanicsvill18934 Farmers
Mechanicsville e
Market/
Road
Produce
Stand
2155 Milford
Milford
18935 Food
Square Pike
Pantry
1118 Slack Rd Newtown
18940 Farmers
Market/
Produce
Stand
771 N.
Morrisville 19067 Food
Pennsylvania
Pantry
Avenue
306 Elephant
Perkasie
18944 Farmers
Rd
Market/
Produce
Stand
Route 202 &
New Britain 18901 Food
Tamanend
Pantry
Avenue
182 W Bridge
New Hope 18938 Farmers
St
Market/
Produce
Stand
5723 Watson & Bristol
19007 Food
Norton Ave
Pantry
None Such Farm Market 215-794-5201
4458 York
Road
Penn Vermont Fruit
Farm
215-795-0230
831 Rolling
Hills Road
Penn View Farm
215-249-9128
1433 Broad
Street
Penndel Food Pantry
215-750-4344
349 Durham
Buckingham 18912 Farmers
Market/
Produce
Stand
Bedminster 18910 Farmers
Market/
Produce
Stand
Perkasie
18944 Farmers
Market/
Produce
Stand
Penndel
19047 Food
158
Website
http://www.manoffma
rketgardens.com/
N/A
http://www.maximuc
ks.com/
http://www.holidayfar
mbuckscounty.com/
http://www.shelterlisti
ngs.org/details/36251/
http://www.milkhouse
farmmarket.com/
http://mpcusa.net/
http://www.myerovfar
m.com/
http://www.newbritai
nbaptistchurch.org/fo
od-larder/
http://www.newhopeb
orough.org/document
s/FarmersMarket.html
https://pa211.commun
ityos.org/zf/profile/ser
vice/id/1582742
http://nonesuchfarms.
com/
https://www.facebook
.com/Penn-VermontFruit-Farm107360655976304/
https://www.facebook
.com/PennViewFarm
N/A
Food Assets- Bucks County
Name
Phone
Perkasie Farmers Market 215-257-5065
Playwicki Farm Farmers 215-357-7300
Market
Plumsteadville Grange
Farm Market
215-766-8822
Produce Connection
215-788-6552
Quakertown Farmers
Market
215-536-4115
Quakertown Food Pantry 215-536-0240
Snipes Farm and
Education Center
215-295-1139
Solebury Orchards
215-297-8079
Solly Brothers
215-357-2850
Soulful Blessings Bristol 215-788-1440
Address
City
Zip
Code
Type
Road
7th & Market St Perkasie
Pantry
18944 Farmers
Market/
Produce
Stand
2350
Feasterville 19053 Farmers
Bridgetown
Market/
Pike
Produce
Stand
5901 Route 611, Plumstead- 18947 Farmers
Easton Road
ville
Market/
Produce
Stand
851 New
Bristol
19007 Farmers
Rodgers Road
Market/
Produce
Stand
201 Station
Quakertown 18951 Farmers
Road
Market/
Produce
Stand
50 North 4th
Quakertown 18951 Food
Street
Pantry
890 West
Morrisville 19067 Farmers
Bridge Street
Market/
Produce
Stand
3325 Creamery New Hope 18938 Farmers
Road
Market/
Produce
Stand
707 Almshouse Ivyland
18974 Farmers
Rd
Market/
Produce
Stand
640 Race Street Bristol
19007 Food
Pantry
Styer Orchard Inc
215-712-9633
97 Styers Lane
Suelke's Roadstand
215-257-7027
1912 Old York
Route 309
Sunflower Kings Farm
215-872-4777
1455 Benner
School Road
Tabora Farm and
215-249-3016
1104 Upper
Langhorne
19047 Farmers
Market/
Produce
Stand
Sellersville 18960 Farmers
Market/
Produce
Stand
Trumbauers- 18970 Farmers
ville
Market/
Produce
Stand
Chalfont
18914 Farmers
159
Website
https://www.facebook
.com/PerkasieFarmers
Market
http://www.playwicki
farm.org/
https://www.facebook
.com/PlumsteadvilleGrange-Farm-Market202768669745812/
N/A
http://www.quakerto
wnfarmersmkt.com/
http://www.quakerto
wnfoodpantry.org/
http://www.snipesfar
m.org/
http://www.soleburyo
rchards.com/
http://www.sollyfarm.
com/
http://www.foodpantri
es.org/li/soulfulblessings
http://www.styerorcha
rd.com/
http://suelkesroadstan
d.com/
http://agmap.psu.edu/
Businesses/index.cfm
?fid=1577
http://www.taborafar
Food Assets- Bucks County
Name
Phone
Orchard
Address
City
Zip
Code
Stump Road
The Lord's Pantry
610-847-2402
4050 Durham
Road
2100 Lower
State Road
Ottsville
The Market at DelVal
University
215-230-7170
The Market at Styer
Orchards
18942
215-757-7646
1121
Woodbourne
Road
Langhorne
19047
Thorpe Farmstand and
Garden Center
215-862-4237
371
Stoneybrook
Road
Newtown
18940
Tifereth Israel Food
Pantry
Traugers FM
215-752-3468
2909 Bristol Rd Bensalem
19020
610-847-5702
335 Island Rd
Kintnersville 18930
Wildemore Farm
215-249-3683
977 Upper
Stump Road
Chalfont
18914
Winding Brook Farm
LLC
215-343-8880
3014 Bristol
Road
Warrington
18976
Windy Springs Farm
215-536-8624
1845 Myers
Road
Quakertown 18951
Wrightstown FM
215-378-3284
2203 Second St Wrightstown 18940
Pike
Doylestown 18901
160
Type
Market/
Produce
Stand
Food
Pantry
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Food
Pantry
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Website
mandorchard.com/sto
re/
http://stjohnsottsville.
org/food-pantry/
http://themarketatdelv
al.com/
http://newsite.styersm
arket.com/
N/A
N/A
http://www.traugers.c
om/
N/A
http://www.windingbr
ookfarm.com/
http://www.windyspri
ngsfarm.com/
http://wrightstownfar
mersmarket.org/
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Code
Ada Mutch Community
Center
610-527-7750
9 S. Bryn
Bryn Mawr
Mawr Avenue
A. G. Farm Market
215-536-8674
2073
Sumneytown
Pike
Harleysville 19438
Ardmore Food Pantry,
St. Mary Episcopal
Church
Bala Cynwyd FM
610-525-3075
36 Ardmore
Avenue
Ardmore
19003
Belmont Ave
Bala
Cynwyd
19004
Bauder Farms
610- 489-948
1151
Collegeville
Rd
Collegeville 19426
Beth Sholom
Congregation
215-887-1342
8231 Old
York Road
Elkins Park
19027
Bethel A.M.E. Church
610-326-9171
401 Beech
Street
Pottstown
19464
Bethel Community
Church of Pottstown
Boyertown Area MultiService
610-326-1700
575 N. Keim
Street
301 Spring
Street
Pottstown
19464
Boyertown
19512
Bright Hope
484-971-6865
468 W. King
St
Stowe
19464
48 N Bryn
Mawr Ave
Bryn Mawr 19010
7910
Washington
Lane
801 W.
Marshall
Street
353 E.
Johnson
Highway
Wyncote
19095
Norristown
19401
Food
Pantry
Norristown
19401
Food
Pantry
19025
Food
Pantry
610-367-6957
Bryn Mawr FM
Calvary Assembly of
God
215-886-0404
Calvary Baptist Soup
Kitchen
610-277-4322
Catholic Social Services
610-279-7372
Chelten Baptist Church
215-646-5557
1601 N.
Dresher
Limekiln Pike
161
19010
Food
Pantry
http://www.elderneto
nline.org/adamutch.html
Farmers http://www.yelp.com/
Market/ biz/a-g-farm-marketProduce woxall
Stand
Food
http://stmarysardmore
Pantry .org/content.cfm?id=3
30
http://balacynwydfar
Farmers mersmarket.weebly.c
Market/ om/
Produce
Stand
Farmers http://www.localharv
Market/ est.org/bauder-farmsProduce M21248
Stand
Food
http://www.bethsholo
Pantry mcongregation.org/m
itzvah-food-pantry
Food
http://bethelamesf.org
Pantry /ministries/foodpantry/
Food
http://bccpottstown.c
Pantry om/index.html
Food
http://www.boyertow
Pantry nareamultiservice.org/communit
y-food-pantry.html
Food
http://www.montcoha
Pantry .org/public_housing_
general_occupancy/d
efault.html
Farmers http://www.brynmaw
Market/ rfarmersmarket.blogs
Produce pot.com/
Stand
Food
http://calvarywyncote
Pantry .com/
http://www.thefigtree.
org/dec09/120109cal
varysoup.html
http://www.cadcom.o
rg/MontgomeryCounty-CupboardList/58/
https://chelten.org
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Food
Pantry
Food
Pantry
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
http://www.hatfieldco
b.org
http://www.pottstown
cluster.org
http://www.collegevil
lefarmersmarket.org
Code
Church of the Brethren
215-855-3064
Cluster Outreach Center
610-970-5995
Collegeville Farmers
Market
610-454-1050
Colonial Neighborhood
Council
610-825-4254
107 E 4th Ave, Conshohock 19428
en
Coordinated Homeless
Outreach Center (CHOC)
610-292-9244
Cooper Creek Farm
Market
610-327-1115
1001 Sterigere Norristown
St. Norristown
State Hospital
Build. 53
1856
Pottstown
Farmington
Avenue
County Line Landscape
Nursery
215-723-8956
811
Harleysville
Pike
Harleysville 19438
Creekside Coop Market
215-557-4480
7909 High
School Rd
Elkins Park
Daily Bread Community
Food Pantry
Daniel's Produce and
Dairy
610-287-0325
845 Gravel
Collegeville 19473
Pike
219 East High Pottstown
19464
Street
Dull's Farm
215-654-0344
1001 Limekiln Ambler
Pike
19002
Emmanual EC Church
215-855-2540
100 S. Main St Hatfield
19440
Frankenfield Farm
Market
215-721-1084
98 Allentown Souderton
Road
18964
Freddy Hill Farms
215.855.1205
1440
Sumneytown
Pike
19446
610-908-2758
1333 Cowpath Hatfield
19440
Road
137 Walnut
Pottstown
19464
Street
460 East Main Collegeville 19426
Street
Lansdale
162
https://www.facebook
.com/ColonialNeighborhoodCouncil114125001943541/
http://rhd-choc.org
19473
Food
Pantry
19464
Farmers N/A
Market/
Produce
Stand
http://countylinenurse
Farmers ry.net
Market/
Produce
Stand
Farmers http://creekside.coop
Market/
Produce
Stand
Food
http://dailybreadcom
Pantry munityfoodpantry.org
Farmers https://www.facebook
Market/ .com/DanielsProduce
Produce AndDairy/
Stand
Farmers N/A
Market/
Produce
Stand
Food
http://www.emmanue
Pantry lecchurch.org
http://agmap.psu.edu/
Farmers Businesses/index.cfm
Market/ ?fid=1374
Produce
Stand
Farmers http://www.freddyhill
Market/ .com
Produce
Stand
19117
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Farmers
Market/
Produce
Stand
Food
Pantry
https://www.facebook
.com/freedsproducest
and/
Code
Freed's Produce
215 -7239588
175 Morwood Harleysville 19438
Rd
Grace Lutheran
Norristown
610-659-7255
506 Haws
Avenue
Glenside Farmers Market
(215) 5656422
Glenside Ave. Glenside
& Easton Rd.
Greener Partners
610.584.6580
3215 Stump
Hall Rd
Collegeville 19426
Hague's Christmas Trees
215-368-4542
755 Forty
Foot Road
Hatfield
Hatfield Church of the
Brethren
Haws Avenue Food
Cupboard/Soup Kitchen
Haws Avenue Methodist
Church
215-855-3064
1333 Cowpath Hatfield
Road
800 W.
Norristown
Marshall St
Hickory Run Produce
610-754-7772
2145 Big
Road
Gilbertsville 19525
Hillside Farms Buffalo
(215) 7238499
750 Cowpath
Road
Telford
18969
Hope Valley Community
Church Food Pantry
215-541-4888
501 Graber
Alley
Red Hill
18073
House of God
610-279-3580
542 Dekalb
Street
Norristown
19401
Iglesia De Dios Renacer
610-277-0255
310 Manor
Ave
Plymouth
Meeting
19462
610-275-1283
Norristown
163
19401
19038
19440
19440
19401
https://www.facebook
.com/pages/GraceLutheranChurch/11615515174
5711
Farmers http://agmap.psu.edu/
Market/ businesses/index.cfm
Produce ?fid=4684
Stand
Farmers http://greenerpartners.
Market/ org
Produce
Stand
Farmers http://www.hagueschr
Market/ istmastrees.com
Produce
Stand
Food
http://www.hatfieldco
Pantry b.org
Food
https://www.facebook
Pantry .com/pages/HawsAve-UnitedMethodistChurch/11606188174
9082
Farmers https://www.facebook
Market/ .com/pages/HickoryProduce Run-FarmStand
Produce/4592352141
05941
Farmers http://www.hillsidefar
Market/ ms.biz
Produce
Stand
Food
http://www.hopevalle
Pantry ychurch.org/valley_fo
od_pantry
Food
https://www.facebook
Pantry .com/pages/TheHouse-ofGod/1200782346756
39
Food
http://www.whitepag
Pantry es.com/business/igles
ia-de-dios-renacerparsonage-plymouthmeeting-pa
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Food
Pantry
Food
Pantry
https://www.facebook
.com/ivfarm
Code
Indian Valley Farmers
Market
(215) 7236627
Main Street
and Penn
Avenue
Telford
18969
Indianvale Farm
(215) 7235670
551 Bergey
Road
Telford
18969
Inter-faith Housing
Alliance
Interfaith at Grace
Lutheran Church
215-659-2642
2086 Parkview Abington
Avenue
503 Haws
Norristown
Avenue
19001
Jenkintown Farmers
Market
267-626-0030
Leedom St &
Greenwood
Ave
Jenkintown
19046
Jenkintown United
Methodist
Jenkintown Wholefoods
FM
215-886-7250
328 Summit
Avenue
1575 The
Fairway
Jenkintown
19046
Jenkintown
19046
Jerusalem Lutheran
Church
Jett's Produce
(610) 2877104
(215) 2576274
311 Second
Street
87 Ridge Rd
Schwenksvil 19473
le
Telford
18969
Jewish Relief Agency
610-660-0190
Bala
Cynwyd
19001
Keystone Opportunity
Center
215-723-5430
125
Montgomery
Avenue
104 N Main
Street
Souderton
18964
Food
Pantry
http://keystoneopport
unity.org
King Produce & Dairy
610-908-2758
219 East High Pottstown
St
19464
https://m.facebook.co
m/DanielsProduceAn
dDairy
Kohler Farms
215-646-4941
1262 Limekiln Ambler
Pike
19002
Lamb Foundation,
Cornucopia Cupboard
215-661-8800
499 E. Walnut North Wales 19454
Street
Farmers
Market/
Produce
Stand
Farmers
Market/
Produce
Stand
Food
Pantry
Lansdale Farmers Market
N/A
Railroad Ave
& Main St
267-269-4573
215.481.0800
164
Lansdale
19401
19446
http://agmap.psu.edu/
Businesses/index.cfm
?fid=4221
http://www.i-fha.org
http://www.uccchristc
hurch.org/html/interfa
ith.html
Farmers https://www.facebook
Market/ .com/JenkintownProduce Farmers-MarketStand
111260468909750/
Food
N/A
Pantry
Farmers http://www.wholefoo
Market/ dsmarket.com/stores/j
Produce enkintown
Stand
Food
http://www.jelc.org
Pantry
Farmers http://agmap.psu.edu/
Market/ Businesses/index.cfm
Produce ?fid=2569
Stand
Food
http://www.jewishreli
Pantry ef.org
http://www.kohlerfar
ms.net
http://www.lambfoun
dationpa.org/cornuco
piacupboard.html
Farmers http://www.lansdalefa
Market/ rmersmarket.org
Produce
Stand
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Food
Pantry
Farmers
Market/
Produce
Stand
Food
Pantry
http://www.lehmanu
mc.org
http://www.localharv
est.org/longviewcenter-foragriculture-M45028
http://food.jenkintow
n.net
Code
Lehman Methodist
Church
Longview Center for
Agriculture
215-675-2110
300 South
York Road
3215 Stump
Hall Rd
Hatboro
Loaves and Fishes
Jenkintown United
Methodist Church
Manna on Main Street
215-886-7250
328 Summit
Avenue
Jenkintown
19046
215-855-5454
713 W. Main
Street
Lansdale
19446
Food
Pantry
http://mannaonmain.o
rg
Mattie N. Dixon
Community Cupboard
215-628-3002
150 N. Main
Street
Ambler
19002
Food
Pantry
http://communitycupboard.org
1329 Willow
Street
Norristown
19401
Food
Pantry
610-584-6580
Meals of Hope Ministry
Soup Kitchen
19040
Collegeville 19426
Mitzvah Klein Food
Pantry
215-698-7300
10100 Jamison Philadelphia 19116
Avenue
Food
Pantry
Narberth Community
Food Bank
610-642-9370
206 Price Ave Narberth
19072
Food
Pantry
http://www.siloambc.
org/index.php/ministr
ies/missionoutreach/meals-ofhope-ministry
https://www.jewishph
illy.org/programsservices/mitzvahfood-project/aboutmitzvah-food-project
http://narberthcommu
nityfoodbank.org
New Hope Baptist
610-275-5814
204 E. Oak
Street
19401
Food
Pantry
http://www.newhopef
gbc.org
New Life Presbyterian
Church-Glenside
215-576-0892
567 N. Easton Glenside
Road
19038
Food
Pantry
http://www.newlifegl
enside.com
NOR-GWYN Food
Cupboard, St. Luke's
Church of Christ
215-699-9342
125 N. Main
Street
North Wales 19454
Food
Pantry
Norristown Salvation
Army Cupboard
610-275-4183
533 Swede
Street
Norristown
19401
Food
Pantry
North Hills Food
Cupboard
215-628-3002
212 Girard
Ave.
North Hills
19038
Food
Pantry
http://www.uccnorth
wales.org/outreachand-service/norgwyn-food-cupboard
http://www.cadcom.o
rg/MontgomeryCounty-CupboardList/58/
http://nhco.org/gethelp/food-pantry/
Patrician Society
610-272-6316
Norristown
19401
Food
Pantry
http://patriciansociety
.org
Positive Aging in Lower
Merion (PALM)
610-642-9370
121 E.
Chestnut
Street
117 Ardmore
Avenue
Ardmore
19003
Food
Pantry
http://www.palmseni
ors.org
Pottstown Salvation
Army Cupboard
610-326-1621
137 King
Street
Pottstown
19464
Food
Pantry
http://www.cadcom.o
rg/MontgomeryCounty-CupboardList/58/
Norristown
165
Name
Food Assets- Montgomery County
Zip
Phone
Address
City
Type
Website
Code
Pottstown Cluster of
Religious Communities
610-970-5995
57 N. Franklin Pottstown
Street
19464
Food
Pantry
http://www.pottstown
cluster.org
Sandy Hill Terrace
610-272-0382
330 Walnut
Street
19401
Food
Pantry
N/A
Shepard's Shelf; Christ
Lutheran Church
215-256-8739
2211 Mainland Kulpsville
Road
19443
Food
Pantry
http://www.christlc2.
org
Shiloh Full Gospel
Baptist Church
610-270-9949
610 George
Street
Norristown
19401
Food
Pantry
http://shilohfgbc.org
Siloam Baptist Church
Soup Kitchen
Meals of Hope Ministry
Soup Kitchen
Sisters of Charity
610-275-8163
1329 Willow
Street
Norristown
19401
Food
Pantry
http://www.siloambc.
org
610-277-5962
Norristown
19401
Food
Pantry
http://sistersofcharity.
com
St. Augustine- Soup
Kitchen
610-279-8890
DeKalb &
Chestnut
Street
1208 Green
Street
Norristown
19401
Food
Pantry
St. Catherine of Siena
SVdP
215-672-2881
321 Widmer
Road
Horsham
19044
Food
Pantry
http://www.episcopal
church.org/parish/staugustine-hippoepiscopal-churchnorristown-pa
http://www.stcatherin
eschurch.org
St. James Episcopal
Church
267-901-4472
3814
Germantown
Pike
Collegeville 19426
Food
Pantry
St. John's Episcopal
Church Soup Kitchen
610-272-4090
23 E. Airy
Street
Norristown
19401
Food
Pantry
http://www.stjamesepiscopal.org/default.
asp?sec_id=14000712
5
http://www.stjohnsno
rristown.org
St. Stanislaus Roman
Catholic Church
215-368-1670
Lansdale
19446
Food
Pantry
http://www.ststanisla
us.com
The Hospitality Center
610-277-1321
51 Lansdale
Avenue (at
Main St)
530 Church
Street
Norristown
19401
Food
Pantry
499 E. Walnut North Wales 19454
St.
Food
Pantry
http://www.lambfoun
dationpa.org
The Lamb Foundation
Norristown
The Open Door
610-948-4818
350 Main
Street
Royersford
19468
Food
Pantry
http://www.opendoor
ministry.info
The Open Link
215-679-4112
452 Penn
Street
Pennsburg
18023
Food
Pantry
http://www.theopenli
nk.org
Trinity United Church of
Christ
610-489-4223
532 E. Main
Street
Collegeville 19426
Food
Pantry
http://www.trinityucc
collegeville.org
Willow Grove SDA
Church
215-657-8364
1556 Fairview Willow
Avenue
Grove
Food
Pantry
http://willowgroveadv
entist.org
166
19090
Appendix E- Other Assets Listing
Name
Other Assets- Bucks and Montgomery Counties
Zip
Phone
Address
City
Type
Website
Code
Abington – Jefferson
Health Clinics
Information
Advanced Living
215-481-2000
1200 Old York
Road
Abington
19001
Other
215-234-4022
19438
Other
Aiding Our Neighbors
215-968-6208
1292 Allentown Lansdale
Road
188 S Canal St Yardley
620 Freedom
BLVD., Sute
101
70 W. Oakland
Avenue, Suite
102
7827 Old York
Road
King of
Prussia
19046
Doylestown
18901
Children www.buckschildcare.
Services com
Elkins Park
19027
Children https://www.bethany.
Services org/philadelphia
121 East
Souderton
Chestnut Street,
Suite 205
18964
Other
Bucks County
(215) 968Association for the Blind 2010
And Visually Impaired –
Thrift Shop
400 Freedom
Drive
Newtown
18940
Bucks County Children
& Youth
(800) 2825785
2325 Heritage
Center Drive
Furlong
18925
Bucks County Health
Department
215-348-6000
55 East Court
Street
Doylestown
18901
Bucks County
Intermediate Unit #22
(800) 7704822
705 Shady
Retreat Road
Doylestown
18901
Care & Share Thrift
Shoppes, Inc.
Catalyst Center for
Nonprofit Mangement
Child, Home &
Community, Inc.
Community ConnectionNavicate
(215) 7230315
(215) 3452727
(215) 3489770
610-278-3522
783 Route 113
Souderton
18964
936 Easton Rd
Warrington
18976
Alzheimer's Association, 800-272-3900
Delaware Valley Chapter
Apple Child Care
Services, Inc. Bucks
County CCIS
Bethany Christian
Services of the Greater
Delaware Valley
Bridge of Hope BuxMont
(215) 3481283
215-376-6200
(267) 9328368
Emilie United Methodist (215) 945Church
5502
19067
204 N. West St., Doylestown 18901
Suite 101
Human Services
19401
Center
Norristown
1st Floor
1430 DeKalb
Street
7300 New Falls Fairless Hills 19030
Rd
167
http://www.jefferson.
edu/abington
http://www.advancedl
ivingcommunities.org
Clothing http://www.uwbucks.
org/resources/aidingour-neighbors/
Other
http://www.alz.org/de
lval/
http://buxmont.bridge
ofhopeinc.org/contact
-us/general-contactinformation/
Clothing http://www.bucksblin
d.org/index.php?optio
n=com_content&vie
w=article&id=47&Ite
mid=57
Bridge http://www.buckscou
Housing nty.org
Program
Other
http://www.buckscou
nty.org/government/h
ealthservices/HealthD
epartment
Bridge http://www3.bucksiu.
Housing org/site/default.aspx?
Program PageID=1
Clothing http://www.careandsh
areshoppes.org
Other
http://catalystnonprofi
t.com/
Children www.chicinfo.org
Services
Other
http://www.montcopa
.org/index.aspx?NID
=1586
Clothing http://emilieumc.com
Name
Other Assets- Bucks and Montgomery Counties
Zip
Phone
Address
City
Type
Website
Code
Family Service
Association of Bucks
County
Full Circle Thrift Shop,
(A Woman's Place)
215-757-6916
4 Cornerstone
Drive
(215) 3400120
Town Center at New Britain 18901
Route 202
Grace’s Closet, Grace
(215) 723United Methodist Church 2144
Langhorne
19047
Reliance Rd. & Telford
South Main
Street
115 Washington Souderton
Ave
211 E. Broad St Souderton
18969
1256 Easton
Road
800 Clarmont
Avenue
Indian Valley Boys and
Girls Club
Indian Valley Chamber
of Commerce
Lutheran Children and
Family Service
MCC, Inc. (Maternal
Child Consortium) &
Warwick Family
Services
215-723-2402
Montgomery County
Health Department
610-278-5117
1430 DeKalb
Street
PO Box 311
New Clothing Outreach
Ministry
c/o Evangelical
Fellowship Chapel
Children http://www.fsabc.org
Services
Clothing http://awomansplace.
org/shop/in_full_swin
g/what_is_in_full_sw
ing.html
Clothing http://gracemethodist.
net
18964
Other
18946
Other
Roslyn
19001
Bensalem
19020
Children
Services
Children
Services
Norristown
19404
Other
(215) 3559529
21 Beechwood Huntingdon
Drive @ County Valley
Line Rd.
19006
North Penn Community
Health Foundation
North Penn School
District
(215) 7165400
(215) 3683960
2506 N. Broad Colmar
St Suite 206
401 E. Hancock Lansdale
St
18915
Clothing http://www.jlc.org/res
ources/countyresourceguide/bucks/newclothing-outreachministry
Other
https://npchf.org/
19446
Other
North Penn Valley Boys
and Girls Club
NOVA Thriftstore
215-855-7791
16 Susquehanna
Ave
Rt. 313 (1628
Swamp Road)
411
Susquehanna
Rd
306 N. 5th
Street, Bldg. 3
229 S. Broad
Street
P.O. Box 2675
Lansdale
19446
Fountainville
18923
Ambler
19002
Perkasie
18944
Lansdale
19446
Harrisburg
17105
1421 Highland
Abington
19001
One House at a Time
(215) 7239472
(215) 8816800
(267) 5257000
(215) 2498000
(215) 3466427
Pennridge FISH
(215) 2577616
Pennsuburban Chamber (215) 362of Commerce
9200
Pennsylvania Department (717) 798of Human Services
9019
Personal Navigator
(215) 572-
168
http://www.bgca.org/
Pages/index.aspx
http://indianvalleycha
mber.com/
http://www.lcfsinpa.o
rg
http://www.warwickf
amilyservices.com
http://www.montcopa
.org/index.aspx?nid=
513
http://www.npenn.org
/site/default.aspx?Pag
eID=1
Other
http://www.npvclub.o
rg
Clothing http://www.novabuck
s.org/thriftshop/
Other
http://www.ohaat.org/
Clothing http://pennridgefish.o
rg
Other
https://pennsuburban.
org/
Other
http://www.dhs.pa.go
v/Feedback/index.ht
m#.VmG4HtCwOec
Other
http://www.vnacs.org
Name
Other Assets- Bucks and Montgomery Counties
Zip
Phone
Address
City
Type
Website
Code
Program of VNA
7880
Avenue
Quality Child Care
Coalition of Bucks Co.
Roslyn Boys & Girls
Club
Souderton Area School
District
Successful Steps
(215) 8062802
(215)-5721520
(215) 7236061
(215) 7818829
705 Shady
Doylestown
Retreat Road
2818 Hammond Roslyn
Plaza
760 Lower Rd Souderton
1230 New
Rodgers Road,
Suite F-3
Suited For Success
(215) 7811230 Norton
0200
Avenue
Sunday Breakfast Rescue (215)741-1010 71 Bellevue
Mission
Avenue
Tabor Children's Service 215-348-4071 601 New
Britain Road
Teen Center
215-757-7823 Oxford Valley
Mall (between
JC Penney and
Macy’s)
2300 East
Lincoln
Highway
The Baby Bureau
(215) 688225 Newton
0538
Road
The Housing Link
(800)-810275 Market St
4434
#509
The Partnership TMA of (215) 997595 Bethlehem
Montgomery County
9100
Pike
Valley Youth House
(215) 442800 N. York
(Bucks County)
9760
Road, Bldg. #22
Wiassahickon School
(215) 619521 Houston Rd
District
8112
Wissahickon Valley
(215) 646209 Race St
Public Library
1072
Your Way Home
(877) 6461 Montgomery
6306
Plaza, Suite 411
18901
19001
18964
/index.php?page=pers
onal-navigatorprogram
Children http://www.bucksqcc
Services c.org
Other
http://www.rbgclub.o
rg
Other
http://www.souderton
sd.org/
Children N/A
Services
Bristol
19007
Bristol
19007
Clothing N/A
Penndel
19040
Doylestown
18901
Langhorne
19047
Clothing http://www.sundaybr
eakfast.org
Children http://www.tabor.org
Services
Children https://www.fsabc.org
Services /program/teen-center/
Warminster
18974
Nationwide
19001
Warminster
18974
Ambler
19012
Ambler
19012
Clothing http://thebabybureau.
org/
Housing http://www.housingli
nk.org
Other
http://www.ptmamc.org/
Children http://www.valleyyou
Services thhouse.org
Other
http://www.wsdweb.o
rg/
Other
http://www.wvpl.org/
Norristown
19404
Other
Montgomery- 18936
ville
169
http://yourwayhome.o
rg
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Abington Hospital
1200 Old York Road
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Jefferson.edu/Abington
Created March, 2016
Abington – Lansdale Hospital
100 Medical Campus Drive
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