Community Health
Needs Assessment
Prepared for
St. John Medical Center
By
VERITÉ HEALTHCARE
CONSULTING, LLC
April 3, 2012
ABOUT VERITÉ HEALTHCARE CONSULTING
Verité Healthcare Consulting, LLC (Verité) was
founded in May 2006 and is located in Alexandria,
Virginia. The firm serves as a national resource that
assists healthcare organizations, hospital associations,
and policy makers with community benefit reporting,
planning, community health needs assessment,
program assessment, and policy and guidelines
development. Verité is a recognized, national thought
leader in community benefit and in the evolving
expectations that tax-exempt healthcare organizations
are being required to meet.
Verité has also been engaged by organizations to
conduct or assist in the preparation of community
health needs assessments (CHNAs).
The CHNA prepared for St. John was directed by the
firm’s president and managed by a senior-level
consultant. Associates and research analysts
supported the work. The firm’s president, as well as
all senior-level consultants and associates, hold
graduate degrees in relevant fields.
More information on the firm and its qualifications
can be found at www.VeriteConsulting.com.
Verité Healthcare Consulting’s work
reflects fundamental concerns
regarding the health of vulnerable
people and the organizations that
serve them
St. John Medical Center
Community Health Needs Assessment
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TABLE OF CONTENTS
INTRODUCTION .............................................................................................................................................................. 2
EXECUTIVE SUMMARY ................................................................................................................................................ 3
COMMUNITY-WIDE PRIORITY NEEDS ................................................................................................................................ 4
PRIORITY NEEDS IN CUYAHOGA COUNTY.......................................................................................................................... 6
PRIORITY NEEDS IN LORAIN COUNTY ............................................................................................................................... 7
APPENDIX..................................................................................................................................................................... A-1
METHODOLOGY ......................................................................................................................................................... A-2
ANALYTIC METHODS ................................................................................................................................................... A-2
PRIORITIZATION PROCESS AND CRITERIA ...................................................................................................................... A-3
INFORMATION GAPS ..................................................................................................................................................... A-3
COLLABORATING ORGANIZATIONS ............................................................................................................................... A-4
DEFINITION OF COMMUNITY ASSESSED ............................................................................................................. A-5
SECONDARY DATA ASSESSMENT .......................................................................................................................... A-8
DEMOGRAPHICS ........................................................................................................................................................... A-8
ECONOMIC INDICATORS ............................................................................................................................................. A-12
1. People in Poverty ......................................................................................................................................... A-13
2. Unemployment Rates ................................................................................................................................... A-14
3. State Budget Cuts......................................................................................................................................... A-14
4. Household Income ....................................................................................................................................... A-16
5. Insurance Coverage ...................................................................................................................................... A-19
6. Population Diversity .................................................................................................................................... A-21
AMBULATORY CARE SENSITIVE DISCHARGES ............................................................................................................. A-23
1. Community-Level Analysis .......................................................................................................................... A-23
2. Facility-Level Analysis ................................................................................................................................ A-25
COUNTY-LEVEL HEALTH STATUS AND ACCESS INDICATORS........................................................................................ A-26
ZIP CODE AND CENSUS TRACT LEVEL HEALTH ACCESS INDICATORS........................................................................... A-32
MEDICALLY UNDERSERVED AREAS AND POPULATIONS ............................................................................................... A-33
HEALTH PROFESSIONAL SHORTAGE AREAS ................................................................................................................. A-34
DESCRIPTION OF OTHER FACILITIES AND RESOURCES WITHIN THE COMMUNITY ........................................................... A-34
REVIEW OF OTHER RECENT COMMUNITY HEALTH NEEDS ASSESSMENTS ..................................................................... A-36
1. The Center for Community Solutions ........................................................................................................... A-36
2. Child and Family Health Services................................................................................................................. A-37
3. The Center for Health Affairs ....................................................................................................................... A-38
4. The Department of Senior & Adult Services ................................................................................................. A-39
5. Lorain County Older Adults Needs Assessment ............................................................................................ A-39
PRIMARY DATA ASSESSMENT .............................................................................................................................. A-40
INTERVIEW FINDINGS ................................................................................................................................................. A-40
INPUT RECEIVED FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY ................................... A-43
1. Identification of Public Health Experts ......................................................................................................... A-44
2. Identification of Health or Other Departments or Agencies ........................................................................... A-45
3. Identification of Community Leaders and Representatives ............................................................................ A-45
4. Identification of Persons Representing the Broad Interests of the Community................................................ A-47
SURVEY FINDINGS ...................................................................................................................................................... A-48
FOCUS GROUP FINDINGS ............................................................................................................................................ A-53
ASSESSMENT SUMMARY ........................................................................................................................................ A-55
SOURCES .................................................................................................................................................................... A-58
INTRODUCTION
This community health needs assessment (CHNA)
was conducted by St. John Medical Center (St. John
or the hospital) because the hospital desires to
understand better community health needs and to
develop an effective implementation strategy to
address such needs. The hospital also has assessed
community health needs to respond to community
benefit requirements.
·
What are the unique health status and/or
access needs for these populations?
·
Where do these people live in the
community?
·
Why are these problems present?
The question of how the organization can best use its
limited charitable resources to assist communities in
need will be the subject of the hospital’s
implementation strategy.
Federal policies require that tax-exempt health
systems undertake community benefit activities and
programs to demonstrate that they merit exemption
from taxation. As specified in the instructions to IRS
Form 990, Schedule H, community benefits are
programs or activities that provide treatment and/or
promote health and healing as a response to identified
community needs.
To answer these questions, this assessment considered
multiple data sources, including secondary data
(regarding demographics, health status indicators, and
measures of health care access), assessments prepared
by other organizations in recent years, and primary
data derived from a survey and interviews with
persons who represent the broad interests of the
community, including those with expertise in public
health.
Community benefit activities or programs seek to
achieve objectives, including:
·
improving access to health services,
·
enhancing public health,
·
advancing increased general knowledge, and
·
·
relief of a government burden to improve
health.1
Demographics, e.g., numbers and locations of
vulnerable people;
·
Economic issues, e.g., poverty and
unemployment rates, and impacts of state
budget changes;
·
Community issues, e.g., homelessness,
housing, environmental concerns,
transportation and traffic, crime, and
availability of social services;
·
Health status indicators, e.g. morbidity rates
for various diseases and conditions, and
mortality rates for leading causes of death;
·
Health access indicators, e.g., uninsurance
rates, Ambulatory Care Sensitive (ACS)
discharges, and use of emergency departments
for non-emergent care;
·
Health disparities indicators; and
·
Availability of healthcare facilities and
resources.
The following topics and data are assessed in this
report:
To be reported, community need for the activity or
program must be established. Need can be established
by conducting a community health needs assessment.
The 2010 Patient Protection and Affordable Care Act
(PPACA) requires each tax-exempt hospital to
“conduct a [CHNA] every three years and adopt an
implementation strategy to meet the community health
needs identified through such assessment.”2
CHNAs seek to identify priority health status and
access issues for particular geographic areas and
populations by focusing on the following questions:
·
Who in the community is most vulnerable in
terms of health status or access to care?
1
Internal Revenue Service. (2011). Instructions for Schedule H (Form
990).
2
111th U.S. Congress. (2010, March). Patient Protection and Affordable
Care Act (PPACA).
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EXECUTIVE SUMMARY
St. John Medical Center Community By the Numbers
·
·
·
·
·
17 ZIP codes in 2 counties: Cuyahoga and
Lorain
Total population 2010: 445,772
o Primary Service Area (PSA): 41% of total
population
o Secondary Service Area (SSA): 59% of
total population
67% of inpatient discharges originate from the
PSA
Population change 2010-2015:
o 1% decline in overall population
o 9% increase in 65+ population
·
·
·
·
·
Cuyahoga County’s 2009 poverty rate higher
than state or national averages
26% of households with incomes < $25,000
2010 Population is 87% White, 6% African
American
Population by race, 2010-2015:
o Projected decline in White populations
o Substantial increase in Asian, MultiRacial, and Other non-white populations
Two service area ZIP codes contain Medically
Underserved Areas
Cuyahoga and Lorain counties contain multiple
Health Professional Shortage Area designations
While the St. John Medical Center community
benchmarks favorably on a variety of health indicators
compared to national and state averages, this
assessment focuses on priority problems that impact
the overall health of the community.
of households had incomes less than $50,000 and 26%
of households had incomes less than $25,000. The
greatest proportions of lower-income households were
located in the western and eastern service area towns
of Lorain and West Park.
Poverty and unemployment in the area create barriers
to access (to health services, healthy food, and other
necessities) and thus contribute to poor health. Racial
and ethnic minorities are more likely to lack economic
and social resources and be at risk for poor health.
Like many states, Ohio has been enacting budget cuts
that are affecting health and human services providers.
These changes include reductions in Medicaid rates,
decreases in general revenue fund appropriations to
community based organizations, and others.
In 2009, Cuyahoga County’s 19% poverty rate was
higher than state and national averages. In 2010, 53%
At St. John Medical Center, 16 percent of discharges
in 2010 were found to be Ambulatory Care Sensitive
St. John Medical Center
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(ACS) or potentially preventable if patients are
accessing primary care resources at optimal rates; 69
percent of ACS discharges were for patients 65 years
of age and older. The most common conditions were:
bacterial pneumonia, congestive heart failure, chronic
obstructive pulmonary disease, and urinary tract
infection. In the St. John Medical Center community,
many of these ACS discharges have occurred for
Medicare and uninsured patients.
Some people living in St. John Medical Center’s
community experience barriers to access. Two
service area ZIP codes have been designated as
Medically Underserved Areas. Cuyahoga and Lorain
counties each contain primary medical care, mental
health, and/or dental Health Professional Shortage
Areas and populations.
Community-Wide Priority Needs
Poor health status results if a complex interaction of
challenging social, economic, environmental, and
behavioral factors combined with a lack of access to
care is present. Addressing these “root” causes is an
important way improve a community’s quality of life
and to reduce mortality and morbidity.
The table that follows describes the health issues
identified through the assessment as priorities across
the entire community served by the hospital. Health
issues are listed in alphabetical order.
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Access to Care
• Lack of Access to Providers
Interviewees and survey respondents identified a difficulty accessing care due to a lack of convenient appointment
times, specifically during weekend and evening hours. Safety net providers described themselves as being “at
capacity” and increasingly are stretched due to higher demand and declines in governmental and philanthropic
funding sources.
• Lack of Affordable and Accessible Care
Community residents identified cost of care, increased insurance co-pays and restrictions, the high cost of
prescription medications, and being uninsured as key access problems. Interviewees also identified public program
eligibility restrictions, the complexity of coverage regulations and other administrative hurdles as barriers to
accessing care.
• Lack of Collaboration and Outreach
Residents perceive a lack of collaboration between local health care providers and a need for increased outreach.
Many community residents lack basic health literacy and healthy lifestyle knowledge and suggested increased
health education. Additionally, some residents are unaware of the services currently available within the
community. Interviewees also mentioned that enhanced collaboration among and training for first responders
such as counselors, police, and teachers may increase awareness of health issues and promote early diagnoses and
treatment.
• Lack of Preventive Services
Residents identified a lack of preventive services (i.e. screenings) as well as a low utilization rate of preventive
services in the community.
• Lack of Services and Care for Seniors
Increased care management appears needed for seniors, especially those without family and social support.
Transportation to health services also is challenging for this population.
• Need for Increased Health Education and Positive Cultural Influences to Change Lifestyles
Interviewees and survey respondents identified increased health education and culture change as important to
improving health.
Health Behaviors
• Prevalent Drug Abuse
Drug use was identified as being prevalent in parts of the community.
Health Conditions
• Prevalent Diet and Exercise - Related Conditions
High rates of obesity, poor diets, and a lack of physical activity are present in much of the community.
Infant and Maternal Care
• High Rates of Infant Mortalities
High rates of infant mortality generally, as well as high rates of Hispanic infant mortality, black Non-Hispanic infant
mortality, black perinatal mortality, and neonatal infant mortality, were identified as priority health issues
throughout the community.
• High Rates of Single Mothers
Residents identified a high rate of single mothers as a priority issue. Inadequate family and social support was also
identified, which may be of particular concern for single mothers and other vulnerable populations.
Mental and Behavioral Health
• Poor Mental and Behavioral Health Status and Lack of Services
The community lacks mental and behavioral health services. The community also suffers from poor mental and
behavioral health status.
Mortality Rates
• High Rates of Colon Cancer
Data show comparatively high rates of colon cancer.
Social and Economic Factors
• High Rates of Financial Hardship
The economic downturn has led to high rates of unemployment and financial hardship.
• Homelessness
Residents identified homelessness in some parts of the community as a priority issue.
St. John Medical Center
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Priority Needs in Cuyahoga County
Cuyahoga County residents account for 46% of the
total community population.
Health Behaviors
• High Rates of Unsafe Sex
Infant and Maternal Care
• High Rates of Post-neonatal Infant Mortality
• High Rates of Teen Pregnancy
• High Rates of Very Low Birth Weight Infants
Mortality Rates
• High Rates of Homicide
• High Rates of Cardiovascular Disease Mortality
• High Rates of Chronic Liver Disease and Cirrhosis
Mortality
Physical Environment
• Poor Community Safety
Characteristics of Cuyahoga County are as follows:
·
Two service area ZIP codes within Cuyahoga
County ranked as “mid to high” and “high”
need in regards to access to healthcare.
·
Two service area ZIP codes in Cuyahoga
County contain food deserts.
The county consistently ranks unfavorably on a
variety of health status and access indicators. The
table to the right lists priority health issues specific to
Cuyahoga County.
When assessing these issues, it is important to note the
probable connections between behavioral, social,
economic, and environmental factors and health
status. For example, high rates of unsafe sex may be
correlated with high rates of infant mortality and teen
pregnancy.
St. John Medical Center
Community Health Needs Assessment
• Poor Air Quality
Social and Economic Factors
• Poor Educational Achievement
6
Priority Needs in Lorain County
Lorain County residents account for 55% of the total
community population.
As in Cuyahoga County, there are probable
connections between identified behavioral, social,
economic, and environmental factors and health status.
For example, high rates of White Non-Hispanic infant
mortality may be correlated with high rates financial
hardship, a lack of access to care, and poor lifestyle
choices.
Characteristics of Lorain County are as follows:
·
33% of St. John Medical Center’s discharges
originate from Lorain County.
·
Unlike the rest of the community, between
2010 and 2015, the Lorain County population
is expected to increase by 2.6%.
·
At 14.4%, Lorain County’s 2009 poverty rate
was lower than the state average and slightly
higher than the national average.
·
The community’s highest proportion of lowincome households reside in Lorain (ZIP
codes 44052, 44053, and 44055).
·
Lorain County has a large concentration of
ZIP codes with “mid to high” or “high” need
in regards to access to healthcare. Lorain (ZIP
codes 44052 and 44055) had the highest
score, indicating the greatest need.
·
Four service area ZIP codes within Lorain
County contain food deserts.
·
Service area ZIP codes in Lorain County
contain Medically Underserved Areas.
Infant and Maternal Care
• High Rates of White Non-Hispanic Infant Mortality
The county also ranks poorly on the rate of white nonHispanic infant mortality.
St. John Medical Center
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APPENDIX
St. John Medical Center
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METHODOLOGY
Analytic Methods
This report begins by identifying the communities (counties and ZIP codes) served by St. John.
Findings based on various quantitative analyses regarding health needs in those areas are
discussed, followed by a review of health assessments conducted by other organizations in recent
years.
The assessment then considers information obtained from interviews with stakeholders who
represent the broad interests of the community, including public health officials and experts, and
St. John-affiliated clinicians, administrators, and staff. Interviews were conducted between
October and December of 2011. The report concludes with a summary of findings, taking into
account all quantitative and qualitative information.
The assessment also quantifies and analyzes ambulatory care sensitive (ACS) discharges. The
ACS discharges methodology quantifies inpatient admissions for diabetes, perforated
appendixes, chronic obstructive pulmonary disease (COPD), hypertension, congestive heart
failure, dehydration, bacterial pneumonia, urinary tract infection, asthma, and other conditions
that, in theory, could have been prevented if adequate ambulatory (primary) care resources were
available and accessed by consumers. 3 Findings from the ACS analysis are presented at the
county, ZIP code, and St. John level of detail.
The methodologies for quantifying ACS discharges have been well-tested for more than a
decade. Disproportionately large numbers of ACS discharges indicate potential problems with
the availability or accessibility of ambulatory care services. The Agency for Healthcare
Research and Quality (AHRQ), part of the U.S. Department of Health and Human Services,
publishes software and methodologies for assessing ACS discharges. The AHRQ software was
applied to analyze the prevalence of ACS discharges in geographic areas served by St John.
The ACS analysis provides a single indicator of potential health problems - allowing
comparisons to be made reliably across geographic areas and hospital facilities. This analysis
also allows an organization to demonstrate a possible “return on investment” from interventions
that reduce admissions (for example, for uninsured or Medicaid patients) through better access to
ambulatory care resources.
Identifying priority community health needs involves benchmarking and trend analysis.
Statistics for several health status and health access indicators thus were analyzed and compared
to state-wide and national benchmarks or goals. The assessment considers multiple data sources,
including indicators from state and federal agencies. Multiple data sources and stakeholder
views are important in assessing the level of consensus that exists regarding community health
needs. If alternative data sources including interviews support similar conclusions, then
confidence is increased regarding the most problematic community health needs in an area.
3
See: http://www.ahrq.gov/data/hcup/factbk5 for more information on this methodology.
St. John Medical Center
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Prioritization Process and Criteria
This assessment considers secondary and primary data including health status and access
indicators, demographic information, previous needs assessments, a survey, and interviews.
Verité applied a ranking methodology to help prioritize the community health needs identified by
these data. Verité generated a list of every health issue identified by the assessment and assigned
a severity score on a scale of 0 to 2, with “2” indicating that the problem was severe, as
indicated, for example, by a prevalence that greatly exceeded Ohio or U.S. averages. An average
severity score was calculated for each category of data (secondary data, interviews, and survey
data) to account for the number of sources that measured each health issue. These averages were
assigned a weight (50 percent, 40 percent, and 10 percent,4 respectively). A final score was
calculated by summing the weighted averages. Table 1 illustrates the prioritization process for
three indicators using Cuyahoga County data.
Table 1: Example Prioritization Process by Data Source and Indicator, Cuyahoga County
Data Source
Alcohol Use
Drug Abuse
County Health Rankings
Community Health Status Indicators Project
Ohio Public Health Data
Healthy People 2010
Behavioral Risk Factor Surveillance Survey
Previous Assessments
Secondary Data - Weighted Average (50%)
0
0
0
0
Infant
Mortality
2
2
2
1
0.88
Interviews
0
2
0.9
0
Survey - Weighted Average (10%)
1
0.1
2
0.2
0
Final Score
0.10
1.10
0.88
Interviews - Weighted Average (40%)
Survey
Source: Analysis of community health needs.
It is important to note that not all health issues were measured by all sources. For example, infant
mortality was only measured by four out of eight sources (Table 1). The methodology thus
takes into account both severity scores for each health issue and the number of sources that
measure each issue.
Information Gaps
No information gaps have affected St. John’s ability to reach reasonable conclusions regarding
community health needs.
4
Survey data was given the lowest weight because survey respondents did not reflect an accurate demographic sample of the St. John
community. Minority and at-risk populations, in particular, were not well represented.
St. John Medical Center
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Collaborating Organizations
None.
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DEFINITION OF COMMUNITY ASSESSED
This section identifies the community assessed by St. John.
St. John’s community is comprised of 17 ZIP codes that extend into (and overlap with) two
counties: Cuyahoga and Lorain (Tables 2 and 3).
Table 2: Service Area Population, 2010
St. John Medical Center
Service
Area
Primary
ZIP Code
44011
44012
44039
44070
44116
44138
44140
44145
Subtotal
44001
44035
44052
44053
44054
Secondary
44055
44107
44126
44135
Subtotal
Town
Avon
Avon Lake
North Ridgeville
North Olmsted
Rocky River
Olmsted Falls
Bay Village
Westlake
County
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Amherst
Elyria
Lorain
Lorain
Sheffield Lake
Lorain
Lakewood
Fairview Park
West Park
Lorain
Lorain
Lorain
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Combined
Population
2010
17,778
24,711
29,353
30,392
18,395
18,878
14,217
30,066
183,790
20,953
64,077
32,415
18,802
12,197
22,819
49,587
15,341
25,791
261,982
445,772
Source: Claritas, Inc., 2011.
In 2010, the St. John Primary Service Area (PSA) included about 184,000 persons and its
Secondary Service Area (SSA) included a population of about 262,000 persons, for a total
service area population of 446,000 (Table 2).
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Table 3: Service Area and County Population Overlap, 2010
County
Cuyahoga
Lorain
Grand Total
Service Area (ZIP
Code) Population
202,667
243,105
445,772
St. John Medical Center
Percent of Service
Area (ZIP Code)
Total County
Population
Population
45.5%
1,270,520
54.5%
297,843
100.0%
1,568,363
Service Area
Percent of Total
County
16.0%
81.6%
28.4%
Source: Claritas, Inc., 2011.
In 2010, the majority (55 percent) of the service area population for St. John resided in Lorain
County; these ZIP codes represented 82 percent of that county’s population as a whole (Table
3). The population of St. John service area ZIP codes represented 16 percent of the total
Cuyahoga County population. Some important secondary data regarding community health
needs only are available at a county level. Findings based on county-wide data should be
interpreted accordingly.
Figure 1 presents a map that shows the community served by the hospital.
Figure 1: Service Area Map
Sources: Microsoft MapPoint and St. John.
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The community was defined based on the geographic origins of St. John inpatients. In 2010,
approximately 67 percent of the hospital’s inpatient discharges originated from the PSA and
another 19 percent from the SSA (Table 4).
Table 4: St. John Inpatient Discharges by ZIP Code and Service Area,
Nine Months Ended September 30, 2010
St. John Medical Center
Service Area ZIP Code
County
Avon
Avon Lake
North Ridgeville
North Olmsted
Rocky River
Olmsted Falls
Bay Village
Westlake
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
483
633
899
907
217
331
353
1,633
5,456
6.0%
7.8%
11.1%
11.2%
2.7%
4.1%
4.4%
20.2%
67.4%
Amherst
Elyria
Lorain
Lorain
Sheffield Lake
Lorain
Lakewood
Fairview Park
West Park
Lorain
Lorain
Lorain
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
70
394
155
55
249
117
191
165
117
1,513
0.9%
4.9%
1.9%
0.7%
3.1%
1.4%
2.4%
2.0%
1.4%
18.7%
Combined
6,969
86.2%
All Other Areas
1,120
13.8%
Total
8,089
100.0%
Primary
44011
44012
44039
44070
44116
44138
44140
44145
Subtotal
Town
Number of Percent of
Discharges
Total
44001
44035
44052
44053
44054
Secondary
44055
44107
44126
44135
Subtotal
Source: OHA discharge data, 2011.
St. John Medical Center
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SECONDARY DATA ASSESSMENT
This section assesses secondary data regarding health needs in St. John’s community.
Demographics
Population change plays a determining role in the types of health and social services needed by
communities. The region served by St. John extends into Cuyahoga and Lorain counties.
Overall, the population living in these 2 counties declined 6.4 percent between 2000 and 2010
and is expected to decline 4.0 percent between 2010 and 2015. The population in St. John’s PSA
and SSA is expected to decline less rapidly than the two counties as a whole (Table 5).
Table 5: Regional Population by County, 2000-2015
County
Cuyahoga
Lorain
Total
St. John Medical Center
Total County Population
Percent Change in Population
2000
2010
2015
2000-2010
2010-2015
1,400,450 1,270,520 1,199,339
-9.3%
-5.6%
275,599
297,843
305,577
8.1%
2.6%
1,676,049 1,568,363 1,504,916
-6.4%
-4.0%
St. John Medical Center
Primary
172,689
Secondary
274,106
183,790
261,982
185,096
255,607
6.4%
-4.4%
0.7%
-2.4%
Service Area
445,772
440,703
-0.2%
-1.1%
446,795
Source: Claritas, Inc., 2011.
The U.S. Census Bureau estimates that the total population of Ohio increased by 1.6 percent
between 2000 and 2010. In the United States, population increased by about ten percent. This
contrasts with a decline in the St. John community.
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Figure 2 shows the anticipated population change by ZIP code from 2010 to 2015. The
populations of nine of the 17 ZIP codes are expected to decrease.
Figure 2: St. John Population Change by ZIP Code, 2010-2015
Sources: Microsoft MapPoint and Claritas, Inc., 2011.
St. John Medical Center
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While the overall population in the community is projected to decline, Table 6 indicates that the
65+ age cohort is expected to increase.
Table 6: Distribution of Population by Age Cohort, 2000-2015
Age/Sex Cohort
St. John Medical Center
Service Area Population
2000
2010
2015
Percent Change in Population
2000-2010
2010-2015
Primary Service Area
0-17
Female, 18-44
Male, 18-44
45-64
65+
Total
75+
24.4%
17.3%
16.6%
26.1%
15.6%
172,689
7.9%
22.2%
15.1%
14.8%
31.6%
16.2%
183,790
7.9%
21.4%
14.6%
14.7%
31.3%
18.0%
185,096
8.2%
-2.9%
-7.3%
-4.8%
29.0%
10.4%
6.4%
7.1%
-3.0%
-2.5%
-0.3%
-0.4%
11.9%
0.7%
3.9%
Secondary Service Area
0-17
Female, 18-44
Male, 18-44
45-64
65+
Total
75+
25.2%
20.2%
19.3%
21.6%
13.7%
274,106
6.7%
23.7%
18.2%
17.5%
26.5%
14.2%
261,982
7.0%
23.0%
17.5%
16.9%
26.9%
15.6%
255,607
7.2%
-10.4%
-13.9%
-13.3%
16.8%
-0.6%
-4.4%
-0.9%
-5.1%
-6.2%
-5.6%
-0.7%
7.4%
-2.4%
0.5%
Combined Service Areas
0-17
24.9%
Female, 18-44
19.1%
Male, 18-44
18.2%
45-64
23.4%
65+
14.4%
Total
446,795
75+
7.2%
23.1%
16.9%
16.4%
28.6%
15.0%
445,772
7.4%
22.3%
16.3%
16.0%
28.8%
16.6%
440,703
7.6%
-7.6%
-11.5%
-10.3%
22.1%
4.0%
-0.2%
2.5%
-4.3%
-4.8%
-3.6%
-0.5%
9.4%
-1.1%
2.0%
23.3%
16.9%
16.3%
28.2%
15.3%
1,568,363
4.9%
22.5%
16.3%
16.0%
28.4%
16.7%
1,504,916
5.0%
-13.5%
-17.7%
-16.0%
18.1%
-5.1%
-6.4%
-5.4%
-7.3%
-7.5%
-5.5%
-3.4%
5.1%
-4.0%
-1.3%
Relevant Counties
0-17
Female, 18-44
Male, 18-44
45-64
65+
Total
75+
25.2%
19.2%
18.2%
22.4%
15.1%
1,676,049
4.9%
Source: Claritas, Inc., 2011.
St. John Medical Center
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The aging of the population may increase demand for health services (Figure 3).
Figure 3: Projected Change in Community-Wide Discharges and Population by County,
2010-2015
8.0%
5.6%
6.0%
4.0%
Percent Change
2.6%
2.0%
0.0%
-2.0%
-4.0%
-6.0%
-3.8%
-5.6%
-8.0%
Cuyahoga
Lorain
County
Change in Population
Change in Discharges
Sources: Analysis of demographic data from Claritas, Inc., 2011, and OHA discharge data, 2011.
Figure 3 assumes that inpatient use rates (discharges per 1,000 persons by age group) remain
constant over the 2010 to 2015 time frame. Because of population aging, demand for inpatient
services may increase more (or decrease less) than the total population.
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Figure 4 indicates that the percentage of the population 65 years of age and older varies by ZIP
code. The towns of Rocky River (ZIP code 44116), Westlake (ZIP code 44145), Fairview Park
(ZIP code 44126), and Elyria (ZIP code 44053) have comparatively high proportions of this
population.
Figure 4: Percentage of Residents Aged 65+, 2010
Sources: Microsoft MapPoint and Claritas, Inc., 2011.
Economic Indicators
The following topics were assessed to examine various economic indicators with implications for
health: (1) people in poverty, (2) unemployment rates, (3) state budget cuts, (4) household
income, (5) insurance coverage, and (6) population diversity.
St. John Medical Center
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1. People in Poverty
Many health needs are associated with poverty. According to the U.S. Census, in 2010, about 15
percent of people in the U.S. and about 16 percent of people in Ohio lived in poverty. Cuyahoga
County reported a poverty rate in 2010 that was higher than national and state averages in that
year (Figure 5).
Figure 5: Percent of People in Poverty, 2010
Cuyahoga
18.2%
Lorain
County
14.3%
Ohio
15.8%
U.S.
0.0%
15.3%
2.0%
4.0%
6.0%
8.0%
10.0% 12.0% 14.0%
Poverty Rate, 2010
Source: U.S. Census Bureau, 2012.
St. John Medical Center
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16.0%
18.0%
20.0%
22.0%
2. Unemployment Rates
In August 2011, Lorain and Cuyahoga counties both experienced lower unemployment rates than
the national average (Figure 6). However, in August 2010, unemployment rates in both counties
exceeded state and national averages.
Figure 6: Unemployment Rates, 2010 - 2011
Cuyahoga
County
Lorain
Ohio
U.S.
0.0%
2.0%
4.0%
6.0%
8.0%
Unemployment Rate
August 2010
10.0%
12.0%
August 2011
Source: U.S. Bureau of Labor Statistics, 2011.
3. State Budget Cuts
The recent recession has had major implications not only for employment but also for state
budget resources devoted to health, public health, and social services. In the 2012-2013 budget,
the state of Ohio reduced Medicaid reimbursements, increased fees assessed to hospitals and
skilled nursing facilities, and reduced funding for resources appropriated for health and human
services. The State’s budget changes include the following:
St. John Medical Center
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Skilled Nursing
·
An increase in the nursing home franchise fee to $11.47 per bed per day in FY 2012
and to $11.67 per bed per day in FY 2013;5
·
A 5.8 percent reduction in the rates that skilled nursing facilities are paid for
Medicaid patients;6
Hospitals
·
An increase in the hospital assessment tax from 1.38 percent to 2.80 percent;7
Other Health and Human Services
·
A decrease in general revenue fund appropriations to $2.0 billion in FY 2012 (4.9
percent less than FY 2011) and a further decrease for FY 2013;8 and
·
Reallocation of funds to the Department of Job and Family Services from the
Department of Aging in FY 2012 and FY 2013, and from the departments of Alcohol
and Drug Addictions Services and Mental Health in FY 2013.9
As described later in this report, stakeholders interviewed for this assessment expressed
significant concerns about the impact of these funding cuts for health and social services
agencies across the community.
Ohio Legislative Service Commission, Budget in Brief, H.B. 153 – As Enacted.
PR Newswire. “Care, Jobs in Ohio Skilled Nursing Facilities Threatened by Federal Cuts.” August 4, 2011.
7
Ohio Legislative Service Commission, Budget in Brief, H.B. 153 – As Enacted.
8
State of Ohio, The Executive Budget Fiscal Years 2012 and 2013, The Jobs Budget: Transforming Ohio for Growth, Book Three: The Budget
Summary, Prepared by the Office of Budget and Management.
9
Ohio Legislative Service Commission, Budget in Brief, H.B. 153 – As Enacted.
5
6
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4. Household Income
Across Lorain and Cuyahoga counties, 26 percent of households are estimated to have had
incomes less than $25,000 in 2010; 53 percent less than $50,000 (Table 7).
Table 7: Percent of Households with Incomes Less than $25,000 and $50,000
by ZIP Code, 2010
Service
Area
St. John Medical Center
Number of
Town
County Households, 2010 $0-$24,999 $0-$49,999
ZIP Code
Total Counties
Primary
44011
44012
44039
44070
44116
44138
44140
44145
Subtotal
44001
44035
44052
44053
44054
Secondary
44055
44107
44126
44135
Subtotal
639,076
26.0%
53.2%
Avon
Avon Lake
North Ridgeville
North Olmsted
Rocky River
Olmsted Falls
Bay Village
Westlake
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
6,505
9,296
11,154
12,347
8,826
7,704
5,645
12,401
73,878
9.4%
10.6%
12.7%
14.0%
16.1%
11.8%
9.4%
10.6%
12.1%
28.0%
29.1%
37.6%
38.4%
41.3%
36.2%
25.5%
29.2%
33.8%
Amherst
Elyria
Lorain
Lorain
Sheffield Lake
Lorain
Lakewood
Fairview Park
West Park
Lorain
Lorain
Lorain
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
7,907
25,876
12,653
8,074
4,647
8,161
23,793
7,001
10,911
109,023
14.1%
24.9%
35.5%
26.8%
14.8%
34.3%
23.4%
18.2%
27.1%
25.2%
37.7%
56.5%
65.4%
56.1%
42.3%
65.4%
55.2%
42.6%
58.1%
55.2%
182,901
19.9%
46.6%
527,017
112,059
27.1%
20.8%
54.4%
47.6%
Combined
Total County
Cuyahoga
Lorain
Source: Claritas, Inc., 2011.
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The greatest proportions of lower-income households in 2010 were located in Lorain (ZIP codes
44052, 44053, and 44055), and West Park (ZIP code 44135) (Figure 7).
Figure 7: Percent of Households with Incomes Less than $25,000 by ZIP Code, 2010
Sources: Microsoft MapPoint and Claritas, Inc., 2011.
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Analysis of demographic data across the two counties served by St. John indicates that ZIP codes
with a preponderance of lower-income households are expected to incur the most significant
declines in population (Figure 8).
Figure 8: Percent of Households < $25,000, 2010 vs. Population Growth by ZIP Code,
2010 - 2015
15.0%
Legend
= ZIP codes of Service
Area
= Other ZIP codes in
Service Area Counties
Population Change, 2010-2015
10.0%
5.0%
0.0%
-5.0%
-10.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Percent of Households < $25,000
Source: Analysis of data from Claritas, Inc., 2011.
St. John Medical Center
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70.0%
80.0%
90.0%
5. Insurance Coverage
As a proxy for where uninsured (self pay) consumers and Medicaid enrollees live, Table 8
portrays the distribution of discharges by ZIP code and by payer.
Table 8: Distribution of Discharges by ZIP Code and Payer,
Nine Months Ended September 30, 2010
Service Area
ZIP Code
Town
St. John Medical Center
Number of
County
Discharges Medicare Medicaid
Self Pay
Private
Other
Primary
44011
44012
44039
44070
44116
44138
44140
44145
Subtotal
Avon
Avon Lake
North Ridgeville
North Olmsted
Rocky River
Olmsted Falls
Bay Village
Westlake
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
1,735
1,876
2,912
3,227
2,077
2,142
1,195
3,668
18,832
44.3%
50.2%
42.5%
49.9%
60.4%
52.2%
46.1%
59.6%
51.3%
5.9%
3.9%
8.4%
9.9%
4.1%
6.1%
3.8%
6.4%
6.6%
2.7%
3.7%
4.1%
4.3%
3.8%
2.7%
2.4%
3.0%
3.4%
45.1%
40.4%
42.7%
33.8%
29.7%
37.3%
46.1%
29.0%
36.7%
2.1%
1.9%
2.2%
2.2%
2.1%
1.6%
1.5%
2.0%
2.0%
Secondary
44001
44035
44052
44053
44054
44055
44107
44126
44135
Subtotal
Amherst
Elyria
Lorain
Lorain
Sheffield Lake
Lorain
Lakewood
Fairview Park
West Park
Lorain
Lorain
Lorain
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
2,288
8,038
4,676
2,527
1,270
2,931
5,353
1,579
3,583
32,245
55.8%
47.6%
46.3%
57.7%
44.0%
47.5%
42.1%
48.8%
45.2%
47.5%
7.6%
18.9%
26.7%
13.0%
10.0%
28.0%
19.2%
6.1%
24.8%
19.3%
3.8%
7.6%
8.8%
5.4%
4.8%
7.5%
8.1%
3.9%
6.2%
7.0%
31.2%
24.7%
17.4%
23.0%
38.9%
16.1%
27.9%
39.1%
22.1%
24.7%
1.6%
1.2%
0.8%
0.9%
2.3%
0.9%
2.8%
2.0%
1.7%
1.5%
51,077
48.9%
14.6%
5.7%
29.1%
1.7%
149,496
32,810
182,306
45.0%
48.1%
45.6%
21.7%
15.4%
20.6%
6.3%
6.0%
6.3%
24.3%
28.9%
25.1%
2.7%
1.5%
2.5%
Combined
Total County
Cuyahoga
Lorain
Total
Source: Analysis of OHA discharge data, 2011.
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Medicaid enrollees were more prevalent in Lorain (ZIP codes 44055 and 44052) and West Park
(ZIP code 44135); Self Pay (uninsured) discharges were most prevalent in Lorain (ZIP code
44052) and Lakewood (ZIP code 44107). Private discharges were most prevalent in Bay Village
(ZIP code 44140) and Avon (ZIP code 44011) (Figures 9 and 10).
Figure 9: Distribution of Self Pay Discharges by ZIP Code, 2010
Source: Microsoft MapPoint and OHA discharge data, 2011.
Figure 10: Distribution of Private Discharges by ZIP Code, 2010
Source: Microsoft MapPoint and OHA discharge data, 2011.
St. John Medical Center
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6. Population Diversity
Across Cuyahoga and Lorain counties, 68 percent of the 2010 population was reported to be
white and 25 percent African American. These statistics for the St. John community ZIP codes
were 87 percent and 6 percent, respectively.
Projections indicate that certain non-white populations are expected to grow at above average
rates (Table 9).
Table 9: Distribution of Population by Race, 2000-2015
Ethnic/Racial Cohort
St. John Medical Center
Service Area Population
2000
2010
2015
Percent Change in Population
2000-2010
2010-2015
Primary Service Area
African American
Asian
Multi-racial
Other
White
Total
0.8%
1.9%
1.2%
0.5%
95.6%
172,689
1.0%
2.4%
1.5%
0.6%
94.5%
183,790
1.1%
2.6%
1.6%
0.7%
94.0%
185,096
34.1%
32.0%
32.8%
37.2%
5.2%
6.4%
9.2%
10.6%
10.6%
12.0%
0.1%
0.7%
Secondary Service Area
African American
Asian
Multi-racial
Other
White
Total
9.4%
0.9%
2.6%
3.5%
83.6%
274,106
10.1%
1.2%
3.3%
4.4%
81.0%
261,982
10.4%
1.3%
3.6%
4.9%
79.9%
255,607
3.4%
22.3%
19.4%
19.5%
-7.4%
-4.4%
-0.2%
6.5%
7.3%
7.5%
-3.8%
-2.4%
Combined Service Area
African American
Asian
Multi-racial
Other
White
Total
6.0%
1.3%
2.1%
2.4%
88.2%
446,795
6.4%
1.7%
2.5%
2.9%
86.6%
445,772
6.5%
1.8%
2.8%
3.1%
85.8%
440,703
4.9%
27.9%
22.4%
20.9%
-2.1%
-0.2%
0.4%
8.9%
8.1%
7.9%
-2.0%
-1.1%
24.3%
1.6%
1.8%
2.0%
70.4%
1,676,049
25.0%
2.1%
2.1%
2.5%
68.3%
1,568,363
25.3%
2.3%
2.3%
2.7%
67.3%
1,504,916
-3.6%
20.2%
13.6%
18.1%
-9.2%
-6.4%
-2.9%
5.9%
4.4%
6.5%
-5.4%
-4.0%
Relevant Counties
African American
Asian
Multi-racial
Other
White
Total
Source: Claritas, Inc., 2011.
St. John Medical Center
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African American communities are most prevalent in the towns of Lorain (ZIP codes 44052 and
44055), West Park (ZIP code 44135), and Elyria (ZIP code 44035) (Figure 11).
Figure 11: Areas with Highest Concentration of African American Residents, 2010
Source: Microsoft MapPoint and Claritas, Inc., 2011.
St. John Medical Center
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Ambulatory Care Sensitive Discharges
This section examines the frequency of ACS discharges within the St. John community and at St.
John.
1. Community-Level Analysis
Disproportionately large numbers of ACS discharges indicate potential problems with the
availability or accessibility of ambulatory (primary) care services. Table 10 indicates for the two
counties served by St. John the proportion of all discharges in 2010 found to be ACS, by county
and by primary payer.
Table 10: ACS Discharges as a Percent of Total by County and Payer,
Nine Months Ended September 30, 2010
County
Cuyahoga
Lorain
Total
Medicare
19.7%
17.1%
19.2%
St. John Medical Center
Private Medicaid Self Pay
8.2%
10.0%
14.6%
7.7%
6.9%
13.7%
8.1%
9.6%
14.4%
Other All Payers
7.2%
14.2%
4.8%
12.4%
7.0%
13.8%
Source: Analysis of OHA discharge data, 2011, using AHRQ software.
The table indicates that across the St. John service area counties, 14 percent of total discharges in
2010 were ACS; 19 percent of Medicare discharges and 14 percent of Self Pay discharges were
ACS.
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Further analysis at the ZIP code level indicates that ACS discharges are more prevalent where
lower-income residents are concentrated; proportionately fewer ACS discharges are associated
with ZIP codes with higher levels of private insurance coverage (Table 11).
Table 11: ACS Discharges by Service Area ZIP Code,
Nine Months Ended September 30, 2010
Service Area
ZIP Code
Town
St. John Medical Center
ACS
Total
County
Discharges Discharges
Total Counties
ACS % of
Total
Households
< $25,000
Private % of
Discharges
25,233
182,306
13.8%
26.0%
25.1%
Primary
44011
44012
44039
44070
44116
44138
44140
44145
Subtotal
Avon
Avon Lake
North Ridgeville
North Olmsted
Rocky River
Olmsted Falls
Bay Village
Westlake
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
Cuyahoga
161
218
335
243
259
216
138
534
2,104
1,735
1,876
2,912
3,227
2,077
2,142
1,195
3,668
18,832
9.3%
11.6%
11.5%
7.5%
12.5%
10.1%
11.5%
14.6%
11.2%
9.4%
10.6%
12.7%
14.0%
16.1%
11.8%
9.4%
10.6%
12.1%
45.1%
40.4%
42.7%
33.8%
29.7%
37.3%
46.1%
29.0%
36.7%
Secondary
44001
44035
44052
44053
44054
44055
44107
44126
44135
Subtotal
Amherst
Elyria
Lorain
Lorain
Sheffield Lake
Lorain
Lakewood
Fairview Park
West Park
Lorain
Lorain
Lorain
Lorain
Lorain
Lorain
Cuyahoga
Cuyahoga
Cuyahoga
304
1,033
594
336
149
383
664
185
568
4,216
2,288
8,038
4,676
2,527
1,270
2,931
5,353
1,579
3,583
32,245
13.3%
12.9%
12.7%
13.3%
11.7%
13.1%
12.4%
11.7%
15.9%
13.1%
14.1%
24.9%
35.5%
26.8%
14.8%
34.3%
23.4%
18.2%
27.1%
25.2%
31.2%
24.7%
17.4%
23.0%
38.9%
16.1%
27.9%
39.1%
22.1%
24.7%
6,320
51,077
12.4%
19.9%
29.1%
21,163
4,070
25,233
149,496
32,810
182,306
14.2%
12.4%
13.8%
27.1%
20.8%
26.0%
24.3%
28.9%
25.1%
Combined
Total County
Cuyahoga
Lorain
Both Counties
Sources: Analysis OHA discharge data, 2011, using AHRQ software, and data from Claritas, Inc., 2011.
St. John Medical Center
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2. Facility-Level Analysis
At St. John, 16.2 percent of all discharges in the first nine months of 2010 were for ACS
conditions.
Table 12 indicates that the most prevalent conditions for St. John’s ACS discharges were for:
bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and
urinary tract infection. These conditions were most prevalent in those 65 years of age or older.
Table 12: Distribution of St. John ACS Discharges by Age Group and Condition,
Nine Months Ended September 30, 2010
St. John Medical Center
0 to 17 18 to 39 40 to 64
Bacterial Pneumonia
0.0%
4.0%
18.9%
Congestive Heart Failure
0.0%
0.8%
9.3%
Chronic Obstructive Pulmonary Disease
0.0%
0.0%
23.0%
Urinary Tract Infection
0.0%
12.0%
13.1%
Diabetes Long-Term Complication
0.0%
5.5%
38.5%
Adult Asthma
0.0%
12.6%
60.9%
Hypertension
0.0%
6.3%
25.0%
Diabetes Short-Term Complication
0.0%
53.8%
38.5%
Dehydration
0.0%
10.0%
30.0%
Pediatric Asthma
100.0%
0.0%
0.0%
Pediatric Urinary Tract Infection
100.0%
0.0%
0.0%
Uncontrolled Diabetes
0.0%
0.0%
54.5%
Perforated Appendix
0.0%
30.0%
30.0%
Pediatric Gastroenteritis
100.0%
0.0%
0.0%
Angina Without Procedure
0.0%
20.0%
40.0%
Pediatric Perforated Appendix
100.0%
0.0%
0.0%
Foreign Body Left In During Procedure
0.0% 100.0%
0.0%
Iatrogenic Pneumothorax
0.0%
0.0% 100.0%
Low Birth Weight
0.0%
0.0%
0.0%
Total
3.4%
5.8%
21.8%
Source: Analysis of OHA discharge data, 2011, using AHRQ software.
St. John Medical Center
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65+
All Cases
77.1%
297
90.0%
259
77.0%
217
74.9%
175
56.0%
91
26.4%
87
68.8%
64
7.7%
26
60.0%
20
0.0%
20
0.0%
13
45.5%
11
40.0%
10
0.0%
6
40.0%
5
0.0%
5
0.0%
1
0.0%
1
0.0%
69.0%
1,308
County-Level Health Status and Access Indicators
The following additional secondary data sources were used to examine county-level health status
and access to care indicators in the St. John community:
1. County Health Rankings;
2. Community Health Status Indicators;
3. Ohio Department of Health; and
4. Behavioral Risk Factor Surveillance System.
County Health Rankings: County Health Rankings, a collaboration between the Robert Wood
Johnson Foundation and the University of Wisconsin Population Health Institute, examines a
variety of health status indicators and ranks each county within each state in terms of health
factors and health outcomes. The health outcomes measure is a composite based on mortality
and morbidity statistics, and the health factors measure is a composite of several variables known
to affect health outcomes: health behaviors, clinical care, social and economic factors, and
physical environment.
County Health Rankings is updated annually. County Health Rankings 2010 relies on data from
2000 to 2008, with most data originating in 2005 to 2007. County Health Rankings 2011 relies
on data from 2001 to 2009, with most data originating in 2006 to 2008.
Table 13 provides a summary analysis of the rankings for the counties served by St. John.
Rankings for Ohio were converted into quartiles to indicate how each county ranks versus others
in the state. Table 13 illustrates the quartile into which each county fell by indicator in the 2011
edition, and also illustrates whether a county’s ranking worsened or improved from 2010. For
example, for the 2011 edition, Cuyahoga County was in the top one-half of Ohio counties for
Access to Care; however, its ranking worsened for this indicator from the previous year.
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Table 13: County-Level Health Status and Access Indicators, St. John
Indicator
Health Outcomes
Mortality
Morbidity
Health Factors
Health Behaviors
Smoking
Diet and Exercise
Alcohol Use
Unsafe Sex
Clinical Care
Access to Care
Quality of Care
Social & Economic Factors
Education
Employment
Income
Family and Social Support
Community Safety
Physical Environment
Air Quality
Built Environment
2011
Cuyahoga
22.5%
36.0%
12.4%
59.6%
80.9%
77.5%
91.0%
86.5%
7.9%
96.6%
96.6%
55.1%
24.7%
24.7%
83.1%
29.2%
5.6%
5.6%
9.0%
3.4%
95.5%
Rank
Change
â
â
â
â
â
2011
Lorain
65.2%
74.2%
52.8%
64.0%
23.6%
28.1%
16.9%
71.9%
48.3%
69.7%
76.4%
58.4%
55.1%
43.8%
69.7%
51.7%
20.2%
34.8%
97.8%
87.6%
92.1%
Rank
Change
â
â
â
â
â
Key
>50th Percentile
25th to 49th Percentile
<25th Percentile
â
Ranking Worsened Between 2010 and 2011
Source: County Health Rankings, 2010 and 2011.
For the St. John community, the indicators that most frequently ranked in the bottom one-half of
Ohio counties were Unsafe Sex, Education, Family and Social Support, and Community Safety.
Indicators that were in the bottom one-half of Ohio counties and that worsened between the 2010
and 2011 editions include Morbidity and Education in Cuyahoga County, and Diet and Exercise
and Community Safety in Lorain County.
Cuyahoga County ranked the most unfavorably with 11 indicators in the bottom half of Ohio
counties, while Lorain County ranked unfavorably on 7 indicators.
Community Health Status Indicators: The Community Health Status Indicators (CHSI)
Project, provided by the U.S. Department of Health and Human Services, compares many health
status and access indicators to both the median rates in the U.S. and to rates in “peer counties”
across the U.S.
Counties are considered “peers” if they share common characteristics such as population size,
poverty rate, average age, and population density. Table 14 highlights the analysis of CHSI
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health status indicators. Cells in the table are shaded if, on that indicator, a county compared
unfavorably both to the U.S. as a whole and to the group of specified peer counties.
Table 14: Unfavorable Health Status Indicators, St. John
Indicator
Breast Cancer
Colon Cancer
Lung Cancer
Coronary Heart Disease
Stroke
Motor Vehicle Injuries
Unintentional Injury
Suicide
Homicide
Births to Unmarried Women
Births to Women 40-54
Births to Women Under 18
Prenatal Care
Premature Births
Low Birth Weight
Very Low Birth Weight
Infant Mortality
Neonatal Infant Mortality
Hispanic Infant Mortality
White non-Hispanic Infant Mortality
Post Neonatal Infant Mortality
Black non-Hispanic Infant Mortality
Cuyahoga
1
1
1
1
Lorain
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Key
Favorable
Unfavorable
Source: The Community Health Status Indicators Project, 2009.
Fifteen of the indicators were unfavorable for Cuyahoga County and 11 were unfavorable for
Lorain County. Both counties compared unfavorably in breast cancer, colon cancer, lung cancer,
coronary heart disease, births to unmarried women, infant mortality, neonatal infant mortality,
Hispanic infant mortality, and black non-Hispanic infant mortality.
Ohio Department of Health: The Ohio Department of Health maintains a publicly-available
data warehouse that includes indicators regarding a number of health status issues. Table 15
summarizes these variables for the St. John community. Following the methodology of the Ohio
Department of Health, the counties were grouped and ranked into thirds.
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Table 15: Ohio Department of Health, Health Status Indicators
Indicator
Maternal and Child Health Indicators
Prenatal Care In First Trimester
Cuyahoga
Lorain
Least
Least
Rate Of Adolescent Births (Ages 15-17)
Least
Average
Very Low Birth Weight, All Births
Least
Least
Very Low
Low Birth
Birth Weight
Weight,Infants
Singleton
Births At Level Iii
Very
Delivered
Facilities
Least
Least
Perinatal Mortality Rate
Least
Least
Ratio Of Black To White Perinatal Mortality Rate
Least
Least
Infant Mortality Rate
Least
Average
Neonatal Mortality Rate
Least
Least
Postneonatal Mortality Rate
Least
Average
Child Death Rate (1-14 Years)
Average
Average
Child Motor Vehicle Crash Death Rate (Ages 1-14 Years)
Other Indicators
Adult Death Rate (Age 18 And Over)
Average
Average
Least
Unintentional Injury Deaths
Motor Vehicle Traffic Related Deaths
Assault (Homicide) Deaths
Least
Least
Intentional Self-Harm (Suicide) Deaths
Average
Average
Cancer Deaths (All Sites)
Average
Average
Lung Cancer Deaths
Average
Breast Cancer Deaths (Females)
Average
Least
Cervical Cancer Deaths (Females)
Average
Least
Colorectal Cancer Deaths
Average
Cardiovascular Disease Deaths
Least
Coronary Heart Disease Deaths
Least
Stroke Deaths
Diabetes Deaths
Chronic Lower Respiratory Diseases (Ages 45+)
Average
Pneumonia/Influenza Deaths
Chronic Liver Disease And Cirrhosis Deaths
Least
Average
Ranking Based on Distribution of Ohio Counties
Top and Middle Third of Counties
Bottom Third of Counties
Source: Ohio Department of Health data warehouse, 2010.
Table 15 indicates that Cuyahoga and Lorain counties had numerous comparatively unfavorable
health status indicators in 2008. Cuyahoga County was in the bottom third of Ohio counties on
14 indicators; Lorain County was in the bottom third on 9 indicators. Both counties were in the
bottom third of Ohio counties in:
·
Prenatal care in first trimester;
·
Very low birth weight, all births;
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·
Very low birth weight, singleton births;
·
Perinatal mortality rate;
·
Ratio of black to white perinatal mortality rate;
·
Neonatal mortality rate; and
·
Assault (homicide) deaths.
The Ohio Department of Health data warehouse also indicates whether counties had achieved
certain Healthy People 201010 goals using an average of 2006-2008 rates. Table 16 indicates
whether or not counties had achieved these goals.
Table 16: Ohio Department of Health, Variation from Healthy People 2010 Goals
Cuyahoga
Maternal and Child Health Indicators
Prenatal Care In First Trimester
-34.1%
Infant Mortality Rate
55.0%
Neonatal Mortality Rate
58.0%
Perinatal Mortality Rate
48.3%
Postneonatal Mortality Rate
61.3%
Ratio Of Black To White Perinatal Mortality Rate
71.4%
Very Low Birth Weight, All Births
59.1%
Other Indicators
Assault (Homicide) Deaths
72.7%
Breast Cancer Deaths (Females)
15.2%
Cancer Deaths (All Sites)
19.6%
Cervical Cancer Deaths (Females)
25.9%
Chronic Liver Disease And Cirrhosis Deaths
73.0%
Chronic Lower Respiratory Diseases (Ages 45+)
45.2%
Colorectal Cancer Deaths
23.6%
Coronary Heart Disease Deaths
13.8%
Intentional Self-Harm(Suicide) Deaths
51.9%
Lung Cancer Deaths
16.5%
Motor Vehicle Traffic Related Deaths
-37.3%
Stroke Deaths
-27.3%
Unintentional Injury Deaths
47.3%
Lorain
-30.2%
39.2%
40.8%
38.4%
53.8%
54.5%
43.8%
14.3%
20.6%
19.5%
44.4%
58.9%
63.9%
23.2%
-17.5%
49.5%
25.4%
0.0%
-27.7%
39.2%
Key
HP 2010 Met
0% to 25% Worse than HP 2010 Goal
25% to 50% Worse than HP 2010 Goal
>50% Worse than HP 2010 Goal
Source: Ohio Department of Health data warehouse, 2010.
10
Healthy People 2010 is a national health promotion and disease prevention agenda established in January 2000 by the U.S. Department of
Health and Human Services.
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Table 16 indicates that, when compared to Healthy People 2010 goals, both counties were
greater than 50 percent worse than the Healthy People 2010 goal for postneonatal mortality, ratio
of black to white perinatal mortality rate, and deaths due to chronic liver disease and cirrhosis.
Two Healthy People 2010 goals, the rate of stroke deaths and the rate of motor vehicle traffic
related deaths, had been achieved in both counties.
Behavioral Risk Factor Surveillance System: The Center for Disease Control and Prevention’s
BRFSS is based on a telephone survey that gathers data on various health indicators, risk
behaviors, healthcare access, and preventive health measures. Data are collected for the entire
U.S. Analysis of BRFSS data can identify localized health issues and trends, and provide
county, state, or nation-wide comparisons. Table 17 compares the prevalence of various
indicators in the St. John community and Ohio. Indicators are shaded if values compare
unfavorably to Ohio averages. Shading is based on percent difference of an indicator from the
Ohio average.
Table 17: Prevalence of BRFSS Indicators and
Variation from the State of Ohio in Service Area Counties, 2010
Indicator
Cuyahoga
Heavy Drinkers*
4.3%
Health
Binge Drinkers**
10.5%
Behaviors Currently Smokes Every Day
13.7%
Currently Smokes Some Days
6.2%
Told Have Asthma
8.1%
Health
Told Have Diabetes
12.9%
Conditions Obese
26.8%
Overweight
35.3%
Poor Mental Health > 21 Days/Month
5.2%
Mental
Not Receiving Needed Emotional and Social Support
4.2%
Health
Rarely Receiving Needed Emotional and Social Support
2.6%
Greater than 6 Teeth Extracted
14.8%
Oral
All Teeth Extracted
9.6%
Health
No Dental Care Visit in Last Year
26.0%
Reported Fair or Poor Health
18.8%
Overall
Inhibited from Usual Activities > 21 Days/Month
3.7%
Health
Poor Physical Health > 21 Days/Month
8.3%
Limited by Physical, Mental, or Emotional Problems
24.5%
Lorain
3.0%
11.3%
10.5%
6.0%
9.0%
17.3%
30.1%
33.8%
4.5%
3.8%
1.5%
15.0%
6.8%
27.1%
24.8%
6.0%
13.5%
30.8%
Ohio
4.2%
10.8%
15.1%
5.0%
9.7%
13.9%
29.3%
34.2%
7.6%
5.2%
3.5%
15.6%
9.8%
28.4%
20.2%
10.3%
9.6%
26.6%
Key
Better than OH
0%-25% worse than OH
25% to 75% worse than OH
>75% worse than OH
Source: CDC BRFSS, 2011.
*Adult men having more than two drinks per day; adult women having more than one drink per day
**Adult males having five or more drinks on one occasion; adult females having four or more drinks on one
occasion.
In both Cuyahoga and Lorain counties, the percent of those who currently smoke some days was
reported as being worse than the state of Ohio. In Cuyahoga County, the percent of heavy
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drinkers and the percent of those who are overweight also were worse than the state. In Lorain
County, the percent of binge drinkers, those with diabetes, those who are obese, those who
reported fair or poor health, those with poor physical health more than 21 days per month, and
those limited by physical, mental, or emotional problems were worse than the state.
ZIP Code and Census Tract Level Health Access Indicators
The following secondary data sources were used to examine ZIP code and census tract level
indicators in the St. John community:
1. Dignity Health (formerly Catholic Healthcare West); and
2. U.S. Department of Agriculture.
Dignity Health (formerly Catholic Healthcare West): Dignity Health (formerly Catholic
Healthcare West), a hospital system based in California, developed the Community Needs Index,
a standardized index that measures certain access variables by county and ZIP code. The
Community Needs Index represents a score assigned to each ZIP code, ranging from “Lowest
Need” (1-1.7) to “Highest Need” (4.2-5). Figure 13 presents the Community Needs Index (CNI)
score of each ZIP code in the St. John community.
Figure 13: Community Needs Index Scores by ZIP Code, 2011
Sources: Microsoft MapPoint and Dignity Health (formerly Catholic Healthcare West) Community Needs
Index, 2011.
Figure 13 indicates that within the St. John community Lorain (ZIP codes 44052 and 44055) had
the highest CNI score, indicating the greatest need. Bay Village (ZIP code 44140) had the
lowest score, indicating the lowest need.
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U.S. Department of Agriculture: The USDA Economic Research Service estimates the number
of people in each census tract that live “more than 1 mile from a supermarket or large grocery
store in urban areas and more than 10 miles from a supermarket or large grocery store in rural
areas.”11 Many government-led policy recommendations aim to increase the availability of
nutritious and affordable foods to people living in these “food deserts.” Figure 14 indicates the
location of identified food deserts in the St. John community.
Figure 14: Location of Food Deserts by Census Tract
Sources: Microsoft MapPoint and U.S. Department of Agriculture, 2009.
Medically Underserved Areas and Populations
HRSA has calculated an Index of Medical Underservice (IMU) score for communities across the
U.S. The IMU score calculation includes the ratio of primary medical care physicians per 1,000
persons, the infant mortality rate, the percentage of the population with incomes below the
poverty level, and the percentage of the population greater than age 64. IMU scores range from
zero to 100 where 100 represents the least underserved and zero represents the most
underserved.12
Any area or population receiving an IMU score of 62.0 or less qualifies for Medically
Underserved Area (MUA) or Medically Underserved Population (MUP) designation. Federally
Qualified Health Centers (FQHCs) may be established to serve MUAs and MUPs. Populations
receiving MUP designation include groups within a geographic area with economic barriers or
cultural and/or linguistic access barriers to receiving primary care. When a population group
does not qualify for MUP status based on the IMU score, Public Law 99-280 allows MUP
designation if “unusual local conditions which are a barrier to access to or the availability of
11
12
http://www.ers.usda.gov/data/fooddesert/documentation.html
Guidelines for Medically Underserved Area and Population Designation.” U.S. Department of Health and Human Services, Health Resources
and Services Administration. http://bhpr.hrsa.gov/shortage/muaguide htm.
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personal health services exist and are documented, and if such a designation is recommended by
the chief executive officer and local officials of the State where the requested population
resides.”13
Within the St. John community, Lorain (ZIP codes 44052 and 44055) and Elyria (ZIP code
44035) contain MUAs.
Health Professional Shortage Areas
An area can receive a federal Health Professional Shortage Area (HPSA) designation if a
shortage of primary care, dental care, or mental healthcare professionals is found to be present.
In addition to areas and populations that can be designated as HPSAs, a facility can receive
federal HPSA designation and a resultant, additional Medicare payment if it provides primary
medical care services to an area or population group identified as having inadequate access to
primary care, dental, or mental health professionals and service capacity.
HPSAs can be: “(1) An urban or rural area (which need not conform to the geographic
boundaries of a political subdivision and which is a rational area for the delivery of health
services); (2) a population group; or (3) a public or nonprofit private medical facility.”14
In the St. John service area, areas and populations designated as HPSAs as of August 2011
include:
Cuyahoga County
·
The homeless population in Northwest Cuyahoga County is designated as a primary care
HPSAs.
Lorain County
·
A dental HPSA exists for a population in East Lorain.
Description of Other Facilities and Resources within the Community
The St. John community contains a variety of resources that are available to meet the health
needs identified in this CHNA. These resources include hospitals, FQHCs, and other agencies
and organizations.
Many facilities in Cuyahoga and Lorain counties have been designated as HPSAs. Lorain
County Health and Dentistry in ZIP codes 44052 and 44055 are the only facilities designated as
HPSAs in St. John service area ZIP codes. These facilities are designated as primary medical
care, mental health, and dental HPSAs.
13
14
Ibid.
HRSA, Bureau of Health Professionals. “Health Professional Shortage Area Designation Criteria.” http://bhpr.hrsa.gov/shortage/hpsacrit.htm.
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Six hospitals are located in St. John service area ZIP codes (Table 18).
Table 18: Information on Hospitals in the
St. John Service Area Counties, 2011
County
Cuyahoga
Lorain
Hospital Name
Town
Lakewood
Westlake
Amherst
Elyria
Lorain
Amherst
Lakewood Hospital
St John Medical Center
Amherst Hospital
EMH Regional Medical Center
Mercy Regional Medical Center
Specialty Hospital Of Lorain
Beds
144
162
60
336
200
30
Sources: Ohio Directory of Registered Hospitals, Ohio Department of Health, 2011, CMS Impact File, 2012,
American Hospital Directory, and hospital facility websites, 2011.
FQHCs were created by Congress to promote access to ambulatory care in areas designated as
“medically underserved.” These clinics receive cost-based reimbursement for Medicare and
many also receive grant funding under Section 330 of the Public Health Service Act. FQHCs
also receive a prospective payment rate for Medicaid services (based on reasonable costs).
Fourteen Federally Qualified Health Centers (FQHCs) are operating within Cuyahoga and
Lorain counties; two of these are located in St. John service area ZIP codes. Both are located in
Lorain (ZIP codes 44052 and 44055) and are operated by Lorain County Health and Dentistry.
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As of 2011, a range of other agencies and organizations are available in each county to assist in
meeting health needs, including county health departments, mental health boards, and human
services departments (Table 19).
Table 19: Other Agencies and Organizations in the St. John
Service Area Counties, 2011
County
Cuyahoga
Lorain
Organization/Agency
Achievement Centers for Children
Bellefaire JCB
Center for Families and Children
Cuyahoga County of Ohio-Health and Human Services
Cuyahoga County Alcohol, Drug Addiction and Mental Health Services Board
Cuyahoga Health Department
Cleveland Department of Public Health
The Free Medical Clinic of Greater Cleveland
The Gathering Place
United Way of Cleveland
Lorain County Board of Mental Health
Lorain Free Clinic
Lorain County General Health District
North Coast Health Ministry
United Way of the Greater Lorain County
Source: Verité research.
Review of Other Recent Community Health Needs Assessments
Verité also considered the findings of other needs assessments published since January 2008.
Five such assessments were conducted regarding the St. John community.
1. The Center for Community Solutions
In January 2010, the Center for Community Solutions published the Northeast Ohio Family
Health Program Needs Assessment Plan.15 That report discussed demographic, economic, and
public health indicators to assess challenges facing family planning services.
The assessment focused on Ashtabula, Cuyahoga, Geauga, Lake, and Lorain counties. Key
findings were:
15
·
In 2007, 44 percent of Ohio pregnancies that resulted in live births were unintended; this
rate is higher than the national average and the Healthy People 2010 Goal for such births.
·
About 43 percent of women were using contraception when they became pregnant.
The Center for Community Solutions. Northeast Ohio Family Health Program Needs Assessment Plan. January 5, 2010.
http://www.communitysolutions.com/assets/1/AssetManager/NA_Final%20010510.pdf
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·
Unintended pregnancies were most common in African American women, young women
under age 20, women with less than 12 years of education, unmarried women, and
women who receive Medicaid.
·
Nearly 11 percent of all live births in the five-county area and 19 percent of live births in
Cleveland in Cuyahoga County were to teens.
·
Both the rate of births to low-weight babies and the rate of premature births have
increased in the last ten years.
·
Nearly 51 percent of female-headed households with children in 2007 were below the
poverty level.
The assessment also found other needs such as helping people with the administrative challenges
associated with Title X funding and Medicaid Waivers, affordable contraceptives, greater access
to public transportation, and better access to affordable primary and specialty care in rural
counties.
2. Child and Family Health Services
In 2010, the Cuyahoga County Board of Health produced an update to the Cuyahoga County
Child and Family Health Services Community Health Indicators Project.16 The project has
compiled information since 1999 on a variety of maternal and child health indicators to examine
trends over time. The Board also measures progress towards meeting Healthy People 2010
goals.
The most recent assessment identified the following goals:
16
·
Reduce the prevalence of smoking during pregnancy;
·
Prevent elevated childhood blood lead levels;
·
Reduce neonatal mortality, infant mortality, and postneonatal mortality, and reduce racial
disparities in infant mortality;
·
Enhance availability of adequate prenatal care;
·
Reduce premature births;
·
Reduce the number of low birth weight babies and very low birth weight babies;
·
Reduce perinatal mortality and racial disparity in perinatal mortality;
The Cuyahoga County Board of Health. Cuyahoga County Child and Family Health Services Community Health Indicators Project: 2010
Update. http://www.ccbh.net/ccbh/export/sites/default/CCBH/pdf/CFHS_Report/CFHS_Indicators_2010_Update.pdf
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·
Assure that more infants receive prenatal care in first trimester; and
·
Reduce neural tube defects.
3. The Center for Health Affairs
The Center for Health Affairs (CHA), a healthcare association in Cleveland, Ohio, sponsored and
published a needs assessment of Northeastern Ohio in 2007.17 That assessment was updated by
the recently published Health Facts 2009.18
Health Facts 2009 reviewed a range of healthcare related topics including demographics, health
related behaviors, health status, affordability of healthcare, access to hospital facilities, and other
topics.
Key findings included:
·
The percentage of Ohio residents classified as obese has been steadily increasing over the
past 8 years.
·
Nearly 28 percent of Ohioans smoked cigarettes. The highest use rate was among 18 to
24 year olds. Annual healthcare costs in Ohio directly caused by smoking were in excess
of $4 billion in 2007.
·
People over the age of 65 and those with annual incomes under $20,000 spent a greater
percentage of their income on health.
·
Wage increases have not kept up with increases in health insurance premiums over the
last seven years.
CHA’s 2007 report Community Health Needs Analysis & Assessment Summary,19 described the
state of the region’s population health, identified major health issues, and recommended
necessary actions.
Key findings included:
17
·
In 2006, the proportion of adults who were overweight was 41 percent.
·
About 27.8 percent of adults studied reported that they smoked cigarettes in 2003‐2004,
almost identical to the statewide rate.
CHA defines “Northeastern Ohio” as Cuyahoga, Lorain, Medina, Ashtabula, Lake, Geauga, Erie, Huron, Ashland, Wayne,
Summit, Portage, and Trumbull counties.
The Center for Health Affairs. Health Facts 2009. http://www.cure-path.com/NR/rdonlyres/AD4CABB2-0A6E-4015-A701769900EC3881/1118/Health_Facts_20092.pdf
19
The Center for Health Affairs. Community Health Needs Analysis & Assessment Summary.
http://www.communitysolutions.com/images/upload/resources/Summary.pdf
18
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·
From 2003 to 2004, 15.5 percent of Northeast Ohio adults (more than 400,000) were
without health insurance at some time in the previous year.
·
In FY 2005, almost half of all children under age five and more than one in three
school‐aged children five to 18 were enrolled in Medicaid or SCHIP.
4. The Department of Senior & Adult Services
The Northern Ohio Data and Information Services published a Community Needs Assessment
for the Department of Senior & Adult Services in 2008. That assessment consisted of six
reports, one of which was titled The Health and Social Services Needs of Older Cuyahoga
County Residents.20 Key findings were that older persons have needs for financial assistance,
transportation, assistance with living independently, and affordable medications. The assessment
emphasized the importance of distributing information for these persons via magazines,
newspapers, and the radio, as many older adults do not use computers or the internet.
5. Lorain County Older Adults Needs Assessment
The Lorain County Office on Aging published the 2008 Lorain County Older Adult Needs
Assessment in March 2008.21 That assessment attempted to determine gaps in the services being
provided to residents over the age of 60. Key needs identified were increased access to
healthcare services, affordable prescription drugs, greater continuity of care, household and
dietary support services, and health education regarding age-specific issues and available
resources. Recommendations included creation of outreach programs, development of a
transportation system, distribution of educational materials, and creation of a centralized referral
system.
The Northern Ohio Data and Information Services. The Health and Social Services Needs of Older Cuyahoga County Residents.
http://dsas.cuyahogacounty.us/pdf_dsas/en-US/CNA/Web_CommNeedsAssment.pdf
21
Lorain County Office of Aging. 2008 Lorain County Older Adult Needs Assessment. http://loraincounty.us/getdoc/2947628d-01ec-4903-96f3485923ec410d/2008-Lorain-County-Older-Adult-Needs-Assessment.aspx
20
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PRIMARY DATA ASSESSMENT
Primary data were gathered through interviews, a community web-based survey, and focus
groups. Findings based on input received are presented below.
Interview Findings
This section discusses findings from 47 interviews conducted with external stakeholders (those
not directly affiliated with St. John) and with internal staff (including St. John employees and
members of St. John medical staff).
The interviews sought community input on health needs in communities served by St. John and
on the types of program interventions or resources that could address identified concerns.
Primary Issues: Stakeholders from the St. John community identified the following issues,
which are ordered based on the frequency and intensity of responses:
·
Economic conditions have negatively impacted healthcare with people, including new
segments of the population such as newly unemployed individuals in their 50s and recent
college graduates who cannot find jobs, responding by skipping meals, halving
medications, avoiding care altogether, ore relying on the emergency room for care. There
has been in an increase in the vulnerable population that does not qualify for Medicaid
but that can’t afford healthcare, such as copays, prescription drugs, or transportation
costs.
·
Population aging is leading to an increased demand for services. Aging and migration
away from the region have left many individuals isolated and without daily physical and
emotional support - conditions that increase admission rates and increase discharge
planning needs. Further, elderly and low-income individuals have unmet needs for
convenient, affordable, and physically accessible transportation.
·
Lack of coordination of services has resulted in over-medicated people, especially
seniors.
·
Individuals and family members lack health knowledge, including wellness and
prevention activities, as well as warning signs of deteriorating medical conditions.
·
People in the community are unaware of the resources that are available, including what
medical services are available locally (as opposed to in Cleveland) - people need to know
what services are available and when these services are available; providers need to
advertise more. However, many providers do not provide sufficient education services
to community residents on their own “turf” and in language that they understand.
·
Community residents expect hospitals’ emergency rooms to provide services on-demand
and on a first-in, first-served basis; hospitals’ marketing efforts contribute to these
expectations.
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·
Individuals are reluctant to utilize nursing homes as they perceive the transition to be
permanent instead of the current focus as a transitional facility back to the home.
·
Family members do not understand medical recovery efforts and frequently insist on
higher acuity (and more expensive) services than is actually needed.
·
There is unmet demand for mental/behavioral health service as providers are at capacity
as evidenced by increasing suicides and individuals who are “acting out.”
·
Economic anxiety, financial stress, and substance abuse are further increasing the
demand for mental/behavioral health services.
·
Financial hardships have increased patient noncompliance with regard to the use of
prescription drugs.
·
Dental care needs are unmet for low-income populations.
·
Obesity and diabetes have reached epidemic levels and have increased the demand for
many services, notably dialysis.
·
There are few physical and emotional support services for new mothers and single
parents.
·
Individuals who do seek care are sicker and need higher levels of service because they
delayed seeking care for financial reasons.
·
Medical professionals are operating beyond capacity - many are physically and
emotionally weakened from continually being asked to provide more services with fewer
resources.
·
Individuals work with hazardous materials as part of their jobs.
·
There are insufficient levels of social workers and nurses.
·
Bedbug infestations are increasing.
Barriers to Access: The most frequently mentioned barriers to accessing care, as ordered by
frequency or intensity of responses, are as follows:
·
The elderly have physical limitations that impact their mobility and access to care.
Decreased insurance coverage, combined with the popularity of high deductible
insurance plans, and reduced prescription drug coverage have decreased the affordability
of services.
·
Some service area residents cannot afford prescription medication.
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·
The service area lacks mental health services for outpatient and ongoing treatment and
has a limited number of psychiatrists in the community to serve the community’s mental
health needs.
·
Most health service providers describe themselves as being at capacity; most providers
lack the resources needed to bring on additional staff. Subsequent time constraints
prevent providers from treating the whole person.
·
There may be reluctance to provide free or reduced services because of a perception that
communities west of Cleveland are more affluent than they actually are. Relatedly, there
is significant “class conflict” that reduces the willingness of certain residents from
seeking support services due to judgment (or perceived judgment) of others.
·
Employed people are reluctant to leave work for medical appointments because of fear of
losing the income for the time or the job itself.
·
Practitioners do not know to where to refer patients in need as referral materials have not
been updated in years.
·
Regulatory requirements that delay or deny healthcare coverage to individuals or that
shift provider attention away from clinical care to documentation.
·
The perceived reputation of Northeast Ohio prevents employers and providers from
moving into the area.
·
Residents tend to first think about downtown Cleveland for medical services due to the
historical concentration of healthcare services there. However, the provider community is
focused on business competition rather than the community health needs.
Suggested Programs: Interviewees indicated that the following types of programs and
initiatives would improve community health:
Collaboratives
·
Increase collaboration between medical, mental health, behavioral health, and social
services.
Community Outreach, Education, and Marketing Efforts
·
Develop and maintain a clearinghouse of services available in the community;
·
Distribute information to the community through non-internet means;
·
Educate the population about medical services and how to appropriately use medical
services;
·
Increase awareness of prescription misuse - intentionally by children using family
members’ prescriptions and unintentionally by the elderly;
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·
Improve diets and diabetes efforts;
·
Secure alternate sources of advertisement for healthy lifestyles educational programs;
·
Teach parenting and grandparenting skills; and
·
Teach people how to recognize heart attacks and strokes.
Health Care Services
·
Open satellite offices for medical services in areas near to residents;
·
Provide follow-up planning for individuals who have participated in a health screening;
·
Develop a 24-hour clinic for low level needs, such as coughs and colds;
·
Place a chemical dependency counselor in the Emergency Room;
·
Provide financial assistance to those individuals who currently cannot work due to illness
and disability; and
·
Provide home visits to high-risk discharged patients.
Operational Initiatives
·
Design wellness and prevention programs around the time and location needs of working
people, such as weekends at grocery stores and churches;
·
Focus activities on youths as this population is often overlooked;
·
Streamline processes to make it easier for individuals with high needs to navigate
throughout the system more efficiently; and
·
Train medical students at FQHCs and free clinics.
Input Received from Persons who Represent the Broad Interests of the
Community
Forty-seven key stakeholders participated in the interview process through individual interviews
with non-profit, governmental, public safety, school, and hospital representatives (Tables 20, 21,
22, and 23). These stakeholders represented organizations that serve or have specific knowledge
about the health and human services needs of the community served by St. John.
The 47 stakeholders were comprised of public health experts; individuals from health or other
departments and agencies; leaders or representatives of medically underserved, low-income, and
minority populations; and other community members.
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Stakeholders often fell into multiple groups. Many public health experts were from health or
other departments or agencies, and were also considered leaders or representatives of medically
underserved, low-income, and minority populations. These public health experts do not appear
on multiple lists.
1. Identification of Public Health Experts
Individuals interviewed with special knowledge of or expertise in public health include (Table
20):
Table 20: Public Health Experts Interviewed
Name
Title
Affiliation
Special Knowledge/Expertise
Through his role at the clinic, Mr. Baumgartner has
special knowledge of the public health needs of lowincome and underserved patients.
Paul
Executive
Baumgartner Jr. Director
Lorain Free Clinic
William M.
Denihan
Chief Executive
Officer
Alcohol, Drug Addiction
Through his role at ADAMHS, Mr. Denihan has special
and Mental Health
knowledge of the mental health needs of Cuyahoga
Services Board
County residents.
(ADAMHS) Board of
Cuyahoga County
Blanche Dortch
Director of
Community
Services
Lorain County Board of
Mental Health
Ms. Dortch has expertise with the mental health and
behavorial health needs of Lorain County residents.
Lee Elmore
Executive
Director
North Coast Health
Ministry
As Executive Director of a North Coast Health Ministry,
Ms. Elmore has special knowledge of the uninsured
patients to whom the clinic provides services.
Kathryn
Gambatese
Past Chair
Valerie A.
Harper, MA
Chief Operating
Officer
Scott S. Osiecki
Director of
External Affairs
Marianne Riley
Intersystem
Programming
Director
Alcohol, Drug Addiction
and Mental Health
Services Board
(ADAMHS) Board of
Cuyahoga County
Alcohol, Drug Addiction
and Mental Health
Services Board
(ADAMHS) Board of
Cuyahoga County
Alcohol, Drug Addiction
and Mental Health
Services Board
(ADAMHS) Board of
Cuyahoga County
Lorain County Board of
Mental Health
Through her role at ADAMHS, Ms. Dortch has special
knowledge of the mental health needs of Cuyahoga
County residents.
Through her role at ADAMHS, Ms. Harper has special
knowledge of the mental health needs of Cuyahoga
County residents.
Through his role at ADAMHS, Mr. Osiecki has special
knowledge of the mental health needs of Cuyahoga
County residents.
Ms. Riley has expertise with the mental health and
behavorial health needs of children participating in
intersystem programs.
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2. Identification of Health or Other Departments or Agencies
Several interviewees were departments or agencies with current data or other information
relevant to the health needs of the St. John community (Table 21). This list excludes
interviewees considered to be public health experts.
Table 21: Individuals from Health Departments or Agencies Interviewed
Name
Title
Affilitiation
Westlake Center for Community
Services
Joyce Able-Schroth Director
Tonnie Alliance
Manager of Special
Events
American Diabetes Association
Dennis Clough
Mayor
City of Westlake
Rebecca Dorman
Director
Cuyahoga County Office of Early
Chilhood Invest in Chidlren
Blanche Dortch
Director of Community
Services
Lorain County Board of Mental Health
Jim Hughes
Mayor
City of Bedford
Molly McDermott
Health Initiatives
Representative
American Cancer Society
Joann Mraz
Educational Program
Director
American Diabetes Association
3. Identification of Community Leaders and Representatives
The following individuals were interviewed because they are considered leaders or
representatives of medically underserved, low-income, and minority populations (Table 22).
This list excludes interviewees considered to be public health experts.
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Table 22: Community Leaders or Representatives Interviewed
Name
Title
Affiliation
Nature of Leadership Role
Joyce AbleSchroth
Director
Westlake Center for
Community Services
Ms. Able-Schroth represents the older adults who
receive social, educational, and recreational services
through the senior center.
Tonnie Alliance
Manager of Special
Events
American Diabetes
Association
Ms. Alliance serves as a representative of community
members with diabetes.
Kristina Austin
Director of Community
Relations and
The Gathering Place
Marketing
Ms. Austin represents the populations with cancer who
receive free-of-charge treatments and programs aimed
at social, emotional, physical, and spiritual needs.
Paul
Executive Director
Baumgartner Jr.
Lorain Free Clinic
Through his role at the clinic, Mr. Baumgartner
represents the low-income and underserved residents
that receive services at the clinic.
Jackie ChavezDirector
Anderson
North Olmsted Senior
Center
Ms. Chavez- Anderson represents the older adults who
receive physical,psychological, social, and spiritual
services at the center.
Rebeca Dorman Director
Cuyahoga County Office of Ms. Dorman represents the low-income and underserved
Early Chilhood Invest in
children who receive early childhood progams through
Children
Cuyahoga County.
Cheryl Dubsky
Superintendent
North Olmsted Schools
Ms. Dubsky represents the children (and their families)
who attend North Olmsted Schools.
Lee Elmore
Executive Director
North Coast Health Ministry
Ms. Elmore represents the uninsured patients to whom
the clinic provides services.
Maureen
Falkenestine
Assistant Director
Catholic Charities, Elyria
Ms. Falkenestine represents the underserved population
who receive services through catholic charities.
Joyce Forristell, Coordinator, Breast
RN
Health Program
St. John Medical Center
Ms. Forristell serves as a representative of community
members with breast cancer.
Dan Keenan
Superintendent
Westlake Schools
Mr. Keenan represents the children (and their families)
who attend Westlake Schools.
Molly
McDermott
Health Initiatives
Representative
American Cancer Society
Ms. McDermott represents area residents with cancer.
Ann Mitchell
Fitness Manager
Westlake Recreation
Center
Ms. Mitchell represents the residents who utilize the
facilities at the Westlake Recreation Center.
Joann Mraz
Educational Program
Director
American Diabetes
Association
Ms. Mraz serves as a representative of community
members with diatebes.
Jeff Nieberding General Manager
The AbbeWood Senior
Living Community
Mr. Nieberding represents the older adult residents who
receive assisted living services.
Rita Price
Director
North Ridgeville Senior
Center
Ms. Price represents the older adults who receive
physical,psychological, social, and spiritual services at
the center.
Marianne Riley
Intersystem
Lorain County Board of
Programming Director Mental Health
Ms. Riley represents the children who receive mental
health and behavorial health care through the Lorain
County Board of Mental Health.
Christie Wiedt,
RN
Child Health and
Safety Community
Activist
Ms. Wiedt serves as a representative of children (and
their families) in unsafe environments.
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4. Identification of Persons Representing the Broad Interests of the
Community
Table 23: Interviewees Representing the Broad Interests of the Community
Name
Title
Affiliation/Location
Paula Adams
Social Worker, St. John Medical Center
St. John Medical Center
Mary Bennett
Nursing Home Council Member
St. Mary of the Woods, Avon Senior Living
Community
Pastor Sherman
Bishop
Pastor, Prince of Peace Church
Prince of Peace Church
Danelle Boomer, RNEmergency Department Nurse, St. John Medical Center
ED
St. John Medical Center
John Burke
Member, St. John Medical Center Board of Directors
St. John Medical Center
Marian Buzzard, RN
RN, Community Outreach Volunteer
St. John Medical Center
Sandy Daly, RN,
MSN
Trauma Program Manager
St. John Medical Center
Sue Griffiths
Nursing Home Council Member
Rae-Ann Skilled Nursing and Rehabilitation
Centers Suburban and Westlake
Rachel Kelch
Social Worker, St. John Medical Center
St. John Medical Center
Julie Kiefer, RN
RN, Community Outreach Volunteer
St. John Medical Center
Kim Krall
Nursing Home Council Member, Huntington Woods Care
Huntington Woods Care and Rehabilitation
and Rehabilitation Center and Riverview Pointe Care Center Center; Riverview Pointe Care Center
Lucile Maher, RN
RN, Community Outreach Volunteer
St. John Medical Center
Diane Nelson
Case Manager, St. John Medical Center
St. John Medical Center
Linda Podhradsky
Case Manager, St. John Medical Center
St. John Medical Center
Kelly Provencher, RN
Nurse Manager, Emergency Department, St. John Medical
Center
St. John Medical Center
Kelly Raddeff, RNED
Emergency Department Nurse, St. John Medical Center
St. John Medical Center
Liz Rodriguez, RNED
Emergency Department Nurse, St. John Medical Center
St. John Medical Center
Candy Sanson
Nursing Home Council Member, Bradley Bay Health Center Bradley Bay Health Center
Matthew Sheehan
EMS Coordinator
St. John Medical Center
Pastor Debbie Spitz Pastor
Church on the Rise
Sr. Mary Dorothy
Tecca, CSA
Parish Catechetical Leader, St. Mary School and Church,
Elyria
St. Mary School and Church, Elyria
Sr. Mary Patricia
Vovk, SND
Principal, St. Peter Church and School, North Ridgeville
St. Peter School and Church, North
Ridgeville
Pastor Debbie Spitz Pastor
Church on the Rise
Christie Wiedt, RN
St. John Medical Center
Child Health and Safety Community Activist
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Survey Findings
St. John sought input from the general public regarding the health of their community through an
online survey. A link was made available on the St. John website to an electronic survey tool.
The survey consisted of 18 questions about a range of health access and health status issues.
Respondent Demographics: One hundred and forty-four (144) respondents from the community
participated in the survey. Nearly 66 percent of respondents were from the PSA.
The majority of respondents reported having private or commercial insurance, seeing a primary
healthcare provider, being always able to see a doctor when needed, and being in good or very
good health. Forty-seven percent were between the ages of 45 and 64.
Health Issues: When asked to identify the top health issues in their community, respondents
most often mentioned issues pertaining to unemployment, obesity, and the need for services and
specialized care for seniors (Figure 15).
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Figure 15: Survey Responses, 2011 - Health Issues22
Obesity, 11%
Unemployment, 14%
Services and Care for
Seniors, 9%
Other, 8%
Diabetes, 7%
Financial Hardship, 1%
Heart
Disease, 6%
Unsafe Sex, 1%
Dental Health, 1%
Hunger, 2%
Don't Know, 2%
Cancer, 6%
Access to and
Affordability of Care, 2%
Lack of Family and
Social Support, 3%
Basic Medical Care
Needs, 3%
Smoking, 4%
Access to and
Affordability of
Insurance, 5%
Drug Abuse, 4%
Poor Mental Health, 5%
Alzheimer's or
Dementia, 5%
Source: Analysis of survey data, 2011.
22
“Other” includes: Affordability of Medications, Alcohol Abuse, Assistance Meeting Basic Needs, Breast Cancer, Childhood Asthma, Childhood Obesity, Community Safety and Violence,
Complexity of Coverage Regulations and Paperwork, Continuity of Care, Coordination and Collaboration of Care Across Providers, Diet and Exercise, Heart Attack, High Level of Bad Debt at
Hospitals, Homelessness, Immunizations, Influenza, Lack of Awareness of Available Services, Lack of Health Care Professionals/Time for Quality Interactions with Patients/ Appointment Times,
Lack of Health Education, Lack of Mental and Behavioral Health Services, Lack of Preventive Services/ Behaviors, Lack of Substance Abuse Services, Lack of Support and Resources for Cancer
Patients, Lack of Urgent Care, Management of Chronic Conditions, Overcrowding, Poor Mental and Behavioral Health Treatment, Prenatal Care, Quality of Health Professionals, Stroke, and Vitamin
D Deficiency.
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Barriers to Care: Respondents were asked to identify the barriers that prevent them from
obtaining the care they need. The most frequently mentioned barriers were a lack of convenient
appointment times (after normal work hours) to see healthcare professionals, and the lack of
access to affordable care and insurance (Figure 16).
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Figure 16: Survey Responses, 2011 – Barriers to Care
Lack of Access and
Affordability of Care
10%
More Convenient Hours
at Physician Offices
74%
Lack of Access and
Affordability of
Insurance
10%
Insurance Restrictions
and Limitations
4%
Lack of Specialty
Services
1%
Source: Analysis of survey data, 2011.
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Lack of Mental Health
Services
1%
Fifty-five (55) percent of respondents reported that they do not need to travel outside of the local
community to get necessary healthcare services; those that do leave in search of vision/eye care,
dental care, primary care, and laboratory and other tests.
When asked about what would make it easier for residents and their families to obtain care, the
most frequently mentioned responses were: more convenient appointment times, affordability,
and proximity (Table 24). Fourteen percent of respondents said that it is not difficult for them to
obtain care.
Table 24: Survey Responses, 2011 – What Would Make it Easier for Residents and
Families to Obtain Care
Percent of
Response
Responses
More Convenient Appointment Times
27.1%
Affordability
15.3%
Proximity
10.2%
Accessible Urgent Care - not ER
6.8%
Wider Selection of Approved Providers
6.8%
Easier Communication with Doctor
3.4%
Access to Insurance
1.7%
Coordination Between Health Care Plans
1.7%
I Don’t Know
1.7%
In-Home Care
1.7%
Knowledge of Available Services
1.7%
Less Overcrowding
1.7%
Parking Facilities
1.7%
Physicians Sign Anthem Contract
1.7%
Shorter Wait Times in ER
1.7%
Specialty Services in the Community
1.7%
It is Not Difficult to Obtain Care
13.6%
Total
100.00%
Source: Analysis of survey data, 2011.
Suggested Programs: Survey respondents indicated that the following types of programs and
initiatives would improve community health:
Improvement in Economy and Government
·
Generate jobs within the community and offer job fairs, employment counseling, and
other related services.
·
Provide access to insurance and healthcare services for the unemployed, uninsured, and
low-income populations.
·
Promote changes to healthcare law and government spending practices to ensure that tax
dollars are spent wisely and those in need can receive care.
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Collaboration, Community Outreach, and Education
·
Establish new and enhance current collaborative efforts with diverse community
organizations and healthcare providers to coordinate care efforts and raise awareness of
locally available services.
·
Enhance education programs, especially for youth, regarding diabetes, obesity, nutrition,
smoking, unsafe sex, and accident prevention.
·
Inspire residents to act on their knowledge of healthy behaviors by promoting positive
messages and role models as an alternative to current negative media influences.
Health Care Services
·
Ensure that all residents have access to affordable preventive care services and provide
regular screenings and follow up services.
·
Increase the availability of residential mental and behavioral health services, including
substance abuse treatment facilities, youth treatment facilities, and inpatient services.
·
Expand services that address the needs of the elderly, addressing safety, mobility, care
management, and independent living.
Operational Initiatives
·
Establish more points of access and expand existing facilities.
·
Support existing and additional low- or no-cost providers, such as free clinics.
·
Encourage physicians to accept a broader range of insurance plans and to offer
appointment times that are more convenient for working individuals and students.
Focus Group Findings
Four focus groups were conducted in January 2012 to validate assessment findings and to help
prioritize identified health needs. Sixty-three (63) community members attended these focus
groups. Participants consisted of public health officials, hospital staff, school superintendents,
and other community health organization representatives.
Meetings began with a short presentation regarding key findings of the needs assessments to
date, including preliminary results of the interviews and public survey. The most commonly
identified healthcare issues, barriers to access, and local trends were discussed. Participants were
then provided an open-ended questionnaire and asked to identify their top three priorities. These
priorities were then assigned points based on their rank: 3 points for each participant’s first
priority, 2 points for the second priority, and 1 point for the third priority. Issues with the highest
number of points are those that are considered most important by the largest number of
participants (Table 25). Priority needs identified by focus group participants paralleled other
findings in this assessment.
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Table 25: Focus Group Responses, 2012
Response
Improved Access, Affordability, and Coverage
Increased Transportation to Health Services
Increased Health Education
Increased Knowledge of Available Resources (Patients and Providers)
Increased Services and Care for Seniors
Prevention of Diet and Activity Related Diseases Through Healthy Lifestyles
Enhanced Mental and Behavioral Health Services
Improved Access to Preventive/Primary Care
Increased Coordination and Collaboration Among Providers
Improved Chronic Disease Management
Increased Community Outreach
Increased Continuity of Care
Retention/Addition of Quality Health Professionals
More Convenient Hours at Physician Offices
Broader Acceptance of Insurance Providers
Mission-Focused Initiatives
Expanded Services for Children
Increased Funding for Services and Programs
Lower Unemployment
Other
Source: Analysis of focus group data, 2012.
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Score
73
40
37
34
34
28
21
18
16
12
10
10
7
7
6
6
5
4
4
63
Percent of
Total
Responses
15.8%
8.4%
8.8%
7.4%
7.4%
6.5%
5.1%
4.2%
3.7%
2.8%
2.3%
2.8%
2.3%
1.4%
0.9%
0.9%
0.9%
0.9%
1.4%
15.8%
ASSESSMENT SUMMARY
St. John assessed the health needs of the community it serves. The assessment considered
multiple data sources, including secondary data (regarding demographics, health status
indicators, and measures of healthcare access), assessments prepared by other organizations in
recent years, and primary data derived from interviews with persons who represent the broad
interests of the community and those with expertise in public health. The following summary of
findings is based on the methodology and analytic methods described in this report:
·
St. John’s service area is comprised of 17 ZIP codes that in 2010 were home to 445,772
persons. The service area extends into two counties: Cuyahoga and Lorain.
·
The population of the hospital’s service area is expected to decline by about 1.1 percent
between 2010 and 2015.
·
Although the population as a whole is predicted to decline, the population 65 years of age
and older is expected to grow between 2010 and 2015, creating an increased demand for
inpatient services. The towns of Rocky River, Westlake, Fairview Park, and Elyria have
comparatively high proportions of this population.
·
Cuyahoga County had a higher poverty rate than the national or state average. Neither
county had a higher rate of unemployment than that experienced by the state or nation in
August 2011.
·
Twenty percent of households in the St. John service area had incomes less than $25,000.
The towns of Lorain and West Park reported the greatest incidence of lower income
households in 2010. Areas with higher proportions of lower-income households are
expected to lose population.
·
Medicaid enrollees were concentrated in the towns of Lorain and West Parks and
uninsured discharges were most prevalent in the towns of Lorain and Lakewood.
·
The St. John community is less diverse than the two counties served –notably 6 percent
of the St. John community is African American, compared to 25 percent in Cuyahoga and
Lorain counties.
·
Cuyahoga and Lorain counties both contain Medically Underserved Areas (MUAs); three
service area ZIP codes (in Lorain and Elyria) are designated as MUAs.
·
Areas and facilities within Cuyahoga and Lorain counties were designated as Health
Professional Shortage Areas (HPSAs).
·
Fourteen Federally Qualified Health Centers (FQHCs) are operating within Cuyahoga
and Lorain counties; two are operating in the town of Lorain.
·
Available health status indicators suggest that healthcare needs vary across the two
service area counties:
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o Cuyahoga County had several significant health status and access problems
identified, especially in regards to infant and maternal health and socioeconomic
factors. Cuyahoga County compared unfavorably for the following indicators:
prenatal care, premature births, low birth weight infants, infant mortality, black
and Hispanic infant mortality, perinatal infant mortality, neonatal infant mortality,
post-neonatal infant mortality, teen pregnancy, unsafe sex, and births to
unmarried women. Additionally, Cuyahoga County reported comparatively high
rates of mortality, morbidity, homicide, coronary heart disease, chronic liver and
cirrhosis mortality, chronic lower respiratory diseases (CLRD), cardiovascular
disease mortality, breast cancer, lung cancer, and colon cancer. Cuyahoga County
ranked unfavorably in the following social and economic factors: income,
educational achievement, family and social support, community safety, and air
quality.
o Lorain County compared unfavorably for several maternal and child health
indicators. Specifically, Lorain County compared unfavorably for the percent of
births to unmarried women, prenatal care, infant mortality, black infant mortality,
white infant mortality, and neonatal infant mortality. Lorain County ranked
unfavorably for breast, colon, lung, and cervical cancers, stroke, chronic liver and
cirrhosis mortality, CLRD, and coronary heart disease. Lorain County also
compared unfavorably in the socioeconomic factors of educational achievement,
family and social support, and community safety. Health behaviors such as
smoking, diet and exercise, and unsafe sex were also ranked in the bottom two
quartiles. Residents also reported poor physical health.
·
Across the St. John service area counties, about 13.8 percent of 2010 discharges were
found to be Ambulatory Care Sensitive (ACS) or potentially preventable if patients were
accessing primary care resources at optimal rates. Low-income consumers exhibited
more ACS discharges than those with higher incomes. Patients with private insurance
coverage had comparatively fewer admissions for ACS conditions.
·
Just over 16 percent of St. John’s discharges were found to be ACS o St. John’s ACS discharges were clustered in: bacterial pneumonia, congestive
heart failure, chronic obstructive pulmonary disease, and urinary tract infection.
o Sixty-nine percent of St. John’s ACS discharges were for persons 65 years of age
and older.
·
In addition to reflecting themes indicated by the quantitative data, analysis of interview
data identified the following community health concerns:
o Delayed treatment for illnesses and ailments due to higher rates of unemployment
and uninsured residents leading to increases in severity of ailments;
o Access to mental and behavioral health resources;
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o Patient noncompliance with prescriptions drugs due to a lack of access to
affordable prescription medication;
o Access to primary care and preventive care due to decreased insurance coverage
and affordability of services;
o Transportation to healthcare providers and services, especially for the elderly;
o Lack of awareness of the resources that are available in the community when
residents have recently joined the vulnerable population; organizations do not
adequately advertise the availability of services;
o Unmet dental care needs for low-income populations; and
o Epidemic levels of obesity and diabetes that have increased the demand for many
services, notably dialysis.
Interviewees also suggested that health education and outreach that focused on preventive care,
healthy habits, and parenting skills could improve the overall health of the community.
Interviewees advocated for greater partnerships and collaboration between providers and
community organizations to increase access, coordinate services, and improve outreach.
Additionally, interviews indicated that individuals in need may be reluctant to acknowledge or
discuss problems that exist.
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